Electronic medical records and usability affect implementation

by Mark Hendrickson

One sport that really bothers me is Major League Baseball. Why? It seems as though the hard-headed people calling the shots, and games for that matter, would rather keep their pride than make the right call.

Instant replay is no secret. It isn’t a new, untested technology—its been around since the mid 50’s and every professional sports league uses it with game-changing results, except the MLB. This has annoyed me for awhile now, but not enough to actually bother me until Armando Galarraga of the Detroit Tigers was robbed of a perfect game due to an umpire’s (admitted) error. This feat has only been done twenty times in the history of the league. A man’s legacy was taken from him simply due to the MLB opting not to use the technology it has available. Sure, baseball is only a game, but what if lives were at stake rather than legacies?

Which brings the question: Is healthcare utilizing all the technology available? Why are there rooms of paper health records when they could be stored on servers the size of a refrigerator or even a deck of cards? Why are doctors carrying around stacks of papers when there are tablet computers the size of a notebook that could put those entire previously mentioned rooms at their fingertips? Why does it seem like you have more technology in your pocket than there is in the exam room?

Although there is no definite answer to these questions, I believe it all boils down to one word: usability.

Many clinicians are resisting the implementation of electronic medical records and other forward-thinking technologies because they dislike change, and technology for that matter. This is likely because the technology that is being imposed on them is difficult to use, or doesn’t feel natural to them.

The benefits of implementing EMR systems are exponential, but I’ll save that for another post. First and foremost we need to get the clinicians who will be using them to accept them. Healthcare software should be designed so that it is flexible enough to accomplish all the necessary tasks, yet intuitive enough so that even a veteran physician can navigate it easily and enjoy doing so.

Clinicians and executives, please keep an open mind about taking the leap into this new digital era. Electronic medical records will be to healthcare what instant replay is to professional sports—essential. Do you want your hospital to be like the MLB?

Mark Hendrickson is an intern at HealthFinch.

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  • jsmith

    The author’s fifth paragraph is self-contradictory. Well, what is it, disliking change or lack of usability (ie lousy systems)? Perhaps you should have figured this out before writing it down. The analysis is easy. Intelligent doctors resist EHRs because EHRs lose money, increase work, and do not improve clinical outcomes.
    Please post your case for exponential benefits here as well.

    • http://medicaleconomics.modernmedicine.com/memag/Health+Care+Information+Technology/Ninety-percent-of-EHR-purchasers-not-on-track-to-m/ArticleStandard/Article/detail/701832 ksmithmd

      Ninety percent of EHR purchasers not on track to meet ‘meaningful use’

    • horseshrink

      Hyperbole loses credibility exponentially. Superlatives here bespeak a blind faith in an immature technology.

      I’ve been an active geek enough decades … and seen/made enough mistakes along the way … to know techno-hoopla when I see it.

      Profusions of EHR hope will temper with time and reality, until the technologies actually mature into something we want enough to need.

  • http://dotui.com ishak kang

    Its really quite sad that the interfaces are so complicated. The legacy paper forms are just as complex, but practitioners have been conditioned to accept this. Today, dynamic and relevant UIs are possible. They can be totally user-centric and help highlight areas of concern with analytics. But, its the business practices of medical software companies that prevent these technologies from being adopted. As patients use their own tools, these walls will break down however. Quite the revolution is coming.

    • horseshrink

      I hope so.

      Some of the stuff that’s out there now really, really sucks. I use such a product daily in a state system.

  • http://fertilityfile.com IVF-MD

    Maybe EMR is truly superior to traditional records. Maybe it is not. In neither case is it justified morally to FORCE doctors to choose one or the other. The freedom to choose is a fundamental human right.

    Now suppose EMR truly is that much better, akin to illuminating your office via electricity rather than with candles. Then it is still the doctor’s choice, but my guess is that 99.99% of doctors will opt for electricity, not because of some arbitrary law, but because it is what’s best for them and their patients.

    Personally, after years of sticking with traditional records, I’m making the transition to EMR myself this year. But it’s because I have researched and researched and finally found one that seems to be a quality and price balance that makes it worthwhile. I’m doing this because I believe it will make my work more efficient.

    And that’s the way it should be. The burden should be on the EMR companies to put out a product of high enough utility and low enough price that doctors would voluntarily embrace adopting them. To try to force this through coercive political means is immoral.

    • jsmith

      Good post. I for one am all in favor of freely chosen EHRs and sincerely hope yours works out for your practice.

      • http://fertilityfile.com IVF-MD

        It costs me zero in hardware and software and I can ease into it on a trial basis. That’s what convinced me to be open-minded and give it a chance. We’ll see. Also, I will amend my statement from “I’m doing this because I believe it will make my work more efficient.” to “I’m doing it because it MIGHT possibly make my work more efficient, so it’s worth a try to see if it lives up to its promise. Also, if it doesn’t work out, my loss of time and money is as little as possible.

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

    This post and subsequent comments have pretty much summed up the situation. Folks like to point out the horrendous usability of EMR as a reason for non-adoption, with physicians’ technophobia and reluctance to “embrace” change as runners up. I don’t think so.

    It’s the utility of EMRs that is the missing piece of the puzzle. For larger establishments, there is some utility to be gained from simply computerizing the business, for smaller practices, much less so, and adoption patterns follow this observation. However, the big bang for the buck cannot be realized until a critical mass of physicians have an EMR and all EMRs communicate with each other, because utility for EMRs lies mainly in communications and collaboration. So we have a chicken and egg situation.

    Asking doctors to get an EMR today, is akin to asking you to buy Outlook knowing full well that 80% of those you do business with are not “on email”. Sure it’s easier to type, sort, format, archive your messages and calendars, but if you want to send something out, you still have to print and fax, and everything you receive still comes through the fax machine, telephone or not at all. Very little utility compared to scribbling a note on a piece of paper, and Outlook is very expensive.
    Once everybody does email, you have gmail choices which are “free” and Outlook choices and all sorts of choices in between. Perhaps, IVF-MD, the government is just trying to artificially push everybody to be “on email” and have a glimpse at the possible utility.
    Is it wise? I don’t know…. It may be, but it also may backfire, as top down pushing often does.

    • jsmith

      “the big bang for the buck cannot be realized until a critical mass of physicians have an EMR and all EMRs communicate with each other, because utility for EMRs lies mainly in communications and collaboration. So we have a chicken and egg situation.”
      Sorry, not buyin’ it. Utility for whom? For me, utility means less computer work, not more, and it means more income, not less, and it means better pt care. The big bang for the buck is strictly theoretical, or it accrues to someone other than the person that actually has to pay for or use the EHR. You set the bar much too low.
      Here’s a better idea for the EHR poponents: Pay us extra to use an EHR, including our start-up costs, all maintenance fees, and reimbursement for the loss of income due to our productivity being gutted, plus a premium to make it worth our while. Otherwise we got nothing to talk about.

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

        Utility for you.

        How do you send a referral on paper? Go get the chart, pull out selected pages, take them to the fax machine, put them on the machine, find the number, dial the number, hope it goes through, wait for the funny noises on the line, take the papers of the fax machine, put them back in the chart in the same places that you pulled them from, put the chart back.

        How will you do a referral in a connected EMR? Stay seated at your desk, bring up the chart, click on several checkboxes for the items you want sent, select the specialist name from a dropdown list, click send.

        Does it work that way now? No. Can it work that way when everybody has a connected EHR? Yes, and it can even be made simpler.

        The biggest problem, as noted by Iowa Family Doc below, is that data entry into the EHR, without each none of the above is possible, is a major pain which causes you to lose productivity, distracts you from the patient, creates garbled long and largely useless documents, and a host of other problems.

        So, yes, I do agree wit horseshrink, let the market fight it out and solve this problem. It is not insurmountable, but if government is making you buy the EMR “as is” anyway, what is the market incentive to provide you a better solution?
        Perhaps vendor will compete for a larger market share of this captive market and create some innovation, and perhaps they will get complacent and hinder the natural pace of innovation…. Time will tell.

        • pcp

          “Go get the chart, pull out selected pages, take them to the fax machine, put them on the machine, find the number, dial the number, hope it goes through, wait for the funny noises on the line, take the papers of the fax machine, put them back in the chart in the same places that you pulled them from, put the chart back.”

          But all of that now is done by a well-trained, low wage medical record clerk.

          With the system you describe, I’ll be sitting in front of the computer at the end of the day, clicking like mad and making mistakes right and left to send out that day’s twenty referrals. I’ll still have the record clerk (now doing primarily scanning) and have an expensive IT specialist on payroll.

          Utility?

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

            Why can’t that low wage record clerk do it on the computer instead? He/she can do stuff in a fraction of the time it took before.

            Granted in a small practice, you won’t be able to cut payroll, but maybe you could use the freed time of that low wage clerk to act as a coach for folks with chronic disease, or perform other low level functions that contribute to better care coordination.

            I do agree with you that as long as the data entry problem remains unresolved, EMRs will not save physician time, and this is a huge problem.

          • jsmith

            Indeed.

          • pcp

            Always appreciate your comments, Ms. Gur-Arie.

            Jsmith asked for an example of utility, and all you could come up with was improved work flow for the lowest paid staffer in the office. We’re really lowering the bar on what we expect from EMRs, aren’t we?

            I think the basic point is that in a well-run office, where every one is functionning at their highest level of competence, EMRs will only benefit those at the bottom of the heap. Everyone else finds themselves doing work that is inappropriate for their level of training (doctor doing data entry, etc.)

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

            Thx, pcp. I do appreciate your realistic, back to earth, comments as well.

            I sort of think that there is something incorrect when asking about utility and comparing to the current status, where physicians spend a few minutes with a patient. There is absolutely nothing in an EHR that can cut that time down farther and with current technology the opposite may be true.
            There are features in EHR that will reduce time that physicians spend today on procedural tasks that are not direct patient care. If you have already delegated those tasks to a lower paid resource, which is great, then EHR will only save time for those resources.
            There is much anecdotal evidence that lower paid resources, when correctly utilized, can improve patient outcomes for those with chronic disease, so this would be one way EHR can benefit people (not you directly, but people in general).
            Another way EHR can benefit people in general is by providing you, or your low paid resource, enough population analytics to manage disease better, and on a more timely basis.
            The only ways I see for EHR to benefit you directly, at this point in time, are 1) if payers decide to pay out significant amounts for “quality” measures “performance” 2) if you can more easily delegate what are now automated tasks to even more low paid resources and ultimately to the computer itself.

        • jsmith

          I will amend your post to reflect current reality:
          How do I send a referral in my current EHR: I fill out a coupla forms and send them electronically to one of our newly hired EHR jockeys, who then prints them out and will then “take them to the fax machine, put them on the machine, find the number, dial the number, hope it goes through, wait for the funny noises on the line, take the papers of the fax machine” and then shred them.
          Progress? Hardly. Wake me up when the technonirvana arrives. Oh, and if something can’t be done about the ueber-time-suck known as data entry, don’t bother.

  • Doc99

    And then there are are the numerous security/privacy issues yet to be worked out.

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

      Just like they don’t put traffic lights at railroad crossings until somebody gets killed, preferably a child, they won’t address security/privacy issues until somebody dies, preferably a child. For example, a teenage boy who commits suicide after receiving coupons for certain bars and specialty stores in the mail, which are accidentally discovered by a “friend” who posts them to the teenager’s Facebook wall, or something like that…. and the entire thing is traced back to some HIT vendor legally selling “de-identified” charts to marketers. Big lawsuit and congressional investigation and “Bobby’s Privacy Law” enacted amidst much moral outrage….

      • horseshrink

        Right. I notice you included an essential ingredient for proper knee-jerk legislation … the memorialized name of the sacrificial victim.

        I live in a state whose health department recently sold “de-identified” EHR information. Yum.

        I like these quotes:

        “A computer lets you make more mistakes faster than any invention in human history – with the possible exceptions of handguns and tequila.” ~Mitch Ratcliffe

        “In a few minutes a computer can make a mistake so great that it would have taken many men many months to equal it.” ~Author Unknown

        http://www.quotegarden.com/computers.html

  • RickMD

    I dread a switch to EMR and I think that mandatory EMR more so than low pay will push a lot of docs out the door early. I did not go to school to be a typist, to hire someone to be a typist seems like a waste of money and the level of detail that EMR demands is preventing us from seeing a tree in the forest. Medicine is about asking the right question not 10 worthless ones. A 85yo WF with PMH of PMR, IDDM and HTN with sudden LOV in OS for 24 hrs is really all I need to start down the correct path. If I need further information I will obtain it in the course of the exam. Medicine is not practiced as a linear pursuit but rather as a web of questions, clinical findings and appropriate testing.
    There is a food mart in NJ called WAWA that could make the worlds best EMR system out of its hoagie ordering system. Te system is intuitive to use, fast, sanitary, and only asks appropriate questions. You see, when you order a hoagie, you know what you want, and there system then ask the appropriate question (size toppings sides how many etc..) The perfect EMR would be the same. I want to order 1 Pneumonia, community acquired. The the computer should ask me, symptoms (fever chills cough), duration ( days…) physical exam ( rales LLL…) and then it would offer an antibiotic page and all this is done on a touch screen literally could be done faster than typing.

    • jsmith

      Superb post. I wish more people were paying attention to your insights.

  • Iowa Family Doc

    I am a solo FP and have looked at several EMRs for my office as well as used the EMR in the local hospital. I am not afraid of technology and generally have been an early adopter of electronic and computer advances.

    The reason I don’t have an EMR is because right now it will force me to work harder, work longer hours and lose money. The $44,000 over 5 years is not enough to change my mind.

    The problem is really the data entry. Yeah you can hire scribes and assistants to do it, but that costs money. Also as others have pointed out EMRs do not think like a doctor, they think like a programmer.

    I believe studies have shown doctor eye contact is much better with a paper chart, indeed one of the most common criticisms I hear from patients who have seen physicians with EMRs is that the doctor never looks at them.

    The notes generated from the huge programs from places like the VA are 99% garbage. I have to search through a 7 page ER note and try to figure out why the patient was there.

    I am ready to embrace EMRs but they have to be efficient and cost-effective. Unfortunately the reality is for a small office the technology isn’t there yet.

    • horseshrink

      Bingo!

      We have a winner!

      • jsmith

        Ditto.

  • http://warmsocks.wordpress.com/ WarmSocks

    As a patient, as long as I’m getting good care, I don’t much care what’s in the file folder stored in my doctor’s locked room full of patient records. OTOH, when that same information is on a computer that other doctors can tap into and make conclusions about, I care quite a bit what those records say. One little piece of wrong information doesn’t matter if nobody sees it; it could be significant if other doctors are accessing that info.

    So now, as doctors switch to EMR, patients either have to live with knowing that misinformation is out there (and we have the potential for being misdiagnosed/mistreated in the future based on that misinformation), or must request copies of everything and then work through the process of requesting corrections – and continuing to get copies/request corrections until the EMR is accurate.

    A usable system is worthless if it’s inaccurate.

  • horseshrink

    Administrators don’t get it.
    Bureaucrats don’t get it.
    Politicians don’t get it.
    Vendors don’t get it.
    Coders don’t get it.

    Build us something we WANT to use, and – gosh golly – we WILL!

    No carrots needed. No sticks.

    Apple and Samsung didn’t have to alter entire professional reimbursement structures to persuade people to buy their smart phones.

    I am convinced that what worked for smart phones – market forces – will also work for EHR technologies.

    I think any factor that boosts market competition in the field of EHR products will benefit clinical end-users. Vendors would then become very sensitive to what customers REALLY want. Also, increased market competition would drive end-user cost down.

    Currently, an end-user’s purchase of an EHR product is like a marriage. I become wed to a patient database structure. If I don’t like the EHR product … too bad. I’m now in a bad marriage that’s too expensive to leave.

    *** Data migration cost + new product cost = prohibitive cost ***

    However, if patient data constructs are broadly standardized … then the cost of data migration could approach zero.

    Example = the World Wide Web. Webpage data constructs are sufficiently standardized now that I can change browsers at will. I can use Safari, Internet Explorer, Firefox … without the World Wide Web needing to change its entire data structure for my use.

    When clinicians can change EHR products at will … as easily as we can already change internet browsers … EHR product design will become competitive enough to give us what WE want … not what a bureaucrat, administrator, or politician wants.

  • ninguem

    If instant replay is so great, why do we still have umpires?

  • PAULMD

    “technonirvana……uber-time-suck”

    brilliant.