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How adopting an EHR is like treating cancer

| Tech | January 31, 2012

EHRs are not ready for prime time. EHR benefits are questionable and there are documented instances where patients’ deaths were directly attributed to an EHR. EHRs are cumbersome and slow. They are unnecessarily complex and built on very old technology. The people who build EHRs have no concern for the end user and therefore EHR usability is pretty abysmal. And EHRs are expensive to buy and expensive to maintain, not to mention that they can completely derail your practice through loss of productivity. The fact that some users seem to do well with their EHRs, and even derive some joy from using them, is not a valid counter argument since most users are not so fortunate and through no fault of their own. There really is no excuse for such failure in this day and age. Just look at the iPad and the iPhone. You can walk into any Apple store and 5 minutes later walk out with a fully functional product with a delightful, intuitive interface, loaded with hundreds of interchangeable apps that even a three year old can use right out of the box. All for a few hundred bucks.

If you happen to be diagnosed with cancer, you will most likely be subjected to years of unpleasant treatments. You will be injected with poison and irradiated with more poison. You will lose your hair, suffer bouts of vomiting and diarrhea and be physically debilitated to the point where you cannot leave your bed. You will most likely have to go through painful surgeries, take all sorts of medications that were shown to kill thousands of rodents and never recover your old self again. And this entire ordeal will cost you a medium size fortune. The fact that some lucky patients go on to win the Tour de France is not really an acceptable rebuttal. Most do not. And there really is no excuse for such incompetence in this day and age when one little pill can cure you of an yeast infection in 24 hours and a $4 course of antibiotics will render you as good as new if you happen to develop a sinus infection. Not to mention the innumerable vaccines that will miraculously prevent you from contracting the plague.

Yes, this is a farfetched analogy, but replacing paper charts with an EHR is not like playing Angry Birds, and if you want a fair chance at survival, you have to tolerate the side effects imposed by the current state of technology. Just like you cannot postpone your cancer treatment until the doctor from Star Trek figures it all out, you cannot postpone transition to EHR until EHRs are “ready for prime time”.  And make no mistake, in today’s reality, paper charts are as big a threat to the survival of an independent medical practice, as any garden variety cancer is to a human body. Paper charts will gradually and irreversibly deprive your practice from the nutrients and oxygen needed for survival, i.e. reimbursement, until it shrivels and dies, or it gets absorbed into a larger organism. The common wisdom seems to favor these outcomes. I do not. If you are one of the fewer and fewer physicians who has no desire to either shrivel or practice Wal-Mart medicine, here is one way to think about your current EHR predicament. (Note: Considering the gravity of the situation, you would be well advised to seek a second opinion.)

Diagnosis. Look around you. EHRs are slowly gaining ground. You would be hard pressed to find a medical group of significant size that does not have one. Data collection is not as voluntary as it is being portrayed, unless of course you think that you are overpaid and can easily absorb cuts in reimbursement. You can choose to make believe that this too shall pass and once Obama is no longer calling the White House home, all will be as it was. Alas, computerization of medical records has bipartisan support, and it always did, due to a rare alignment of powerful financial interests and progressive ideology. If you want to continue the practice of medicine, you will need to use the tools of the trade. For better or worse, both the trade and its tools are being redefined. Barring a global disaster, the chances of spontaneous remission are nil.

Staging. How bad is it doc? Well, it won’t kill you tomorrow, but the longer you wait, the harder and more expensive it will become, the fewer the choices and the lower the chances of a good outcome. Both public and private payers are experimenting with new reimbursement methods. These pilots, or projects, are cropping up everywhere, supported by grants and all sorts of tax payer monies. The goals may be different and the rules of engagement are certainly different, but these arrangements have one thing in common. They all prefer that you generate and consume large amounts of clinical data in electronic format. You will need an EHR for that.

Treatment. A physician-centered approach to the problem suggests that you should be informed of your options and allowed to make a decision based on your personal and cultural preferences. Since medical practices are not people, you may choose to euthanize your practice. This may make perfect sense if your practice had a long and productive life and your medical career is in its twilight years anyway. A less terminal option would be to allow your practice to be hooked up to the machinery available in large health systems. You will still have to use an EHR, but your new employer will undertake the mitigation of most side effects. There is a slim chance that someday you may be able to remove the tubes and resume private practice, but while your medical career can survive indefinitely, your practice as you know it now is not likely to recover. Or you could make a stand and fight for your independence.

Prognosis. By definition there could be no blinded trials for EHR utilization, and by omission there are no randomized control trial results to learn from. The anecdotal evidence suggests that many thousands of physicians in independent practice are surviving just fine after EHR implementation. Some would say that they are doing better than ever now, and others have resigned to the new ways of doing business. For most, the life threatening problem has been transformed into a manageable chronic condition. It must be noted however, that a significant number of physicians is currently in need of life-support from health systems and hospitals, and many of these are post EHR implementation. We cannot be certain, since there is almost no literature on the subject, but it is highly probable that practices suffering from a relapse have had multiple comorbidities to start with and/or developed other life threatening conditions since. There are no guarantees of course, but if you have an otherwise healthy practice, a positive outlook and a supportive environment, chances are good that transition to EHR now will enable your independent practice to survive and thrive for many years to come. And the opposite is also true.

Margalit Gur-Arie is a partner at EHR pathway, LLC and Gross Technologies, Inc. She blogs at On Healthcare Technology.

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  • Anonymous

    We have looked at more than 20 EHR’s. None of them connect to one another.
    ( the  purported intent) .
    Some of them are made by a lab  ( to make a profit)  or connected to one, and charge extra for connecting to another  or to a radiology site- or want you to use their billing platform,( Thereby taking a cut of your income,)
    Some of them make you click through far too many windows. 
    Word of mouth from other practices who have shed one or another is that 1) for some of them the demo has nothing to do with the product.2) some are better made for specialists.
    We picked one, and thank God, ran into computer tech issues before implementation- it just folded on 23,000 practices, with the ultimate bait and switch. It will refund the money paid by the physician for the product  but not for the time spent in transferring data.
    But as we were training- the trainers had   no idea why we  might want the EMR  to remind us that a colonoscopy should   be done in 2 or 3 years instead  of seven. ( there was no provision for someone with inflammatory bowel disease) , or a q 6 month  serial mammogram if the one before was questionable.  There was no answer to gender other than male or female, and the field would not close without an answer. This was supposedly a Medicare requirement. ( I have no idea what the plan for transgender patients is under Medicare) We were supposed to ask a patient’s race and religion as they were checking in at the front desk. (This may be okay for Medicare, but may break other laws)
    I just reboarded- it was clear that any attempt at this in the future required some kind of EMR- but the other end of it- a patient survey generated by the ABIM was impossible. My  70 and eighty year olds couldn’t figure out how to complete it correctly, and I had to hire someone to mail them out and hand enter them,Perhaps the next generation of Medicare patients will be able to handle this- but it’s not user-friendly now..
    We are going to generate a lot of data- but I’m not sure how much is going to be useful. I already  get insurance letters saying I haven’t checked a HGB A1c in 2 years ( I send them 3) ,or a colonoscopy- mail the results  or mammogram- 
    Occasionally they are useful- may patient isn’t taking their meds. Mostly, it just makes more work.
    And makes for a bigger disincentive to take Medicare.

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

      There was a tremendous policy error made when it was decided to lower the bar on EMR certification for meaningful use to approximately 1 micron above the floor. There are now well over 1000 “products” to choose from, with maybe a couple of dozen or less being anywhere close to useable software. From your description above, you ran into one that wasn’t.

      It doesn’t have to be like that. I am not about to make outrageous claims here, but there are EMRs that are tolerable, and in small ways maybe even helpful. You just need to find one. Check out the AAFP reader survey on the subject. It’s a good starting point. http://www.nxtbook.com/nxtbooks/aafp/fpm_20110708/#/26

      Opting out of Medicare may delay the inevitable, but is not going to make this go away, since private payers are on board with EMRs and data analytics. Opting out of insurance altogether may buy you some time, but eventually you will have to interact with hospitals and specialists who will not be happy to receive faxes or labs that cannot fax results any longer.

      • Anonymous

        I still think lubricating market competition by unraveling “vendor-locked data by design” is the best way to speed maturation of the EHR world.

        When docs can change EHRs at will, vendors will be much more interested in creating products they actually want, and at more affordable prices.

        The push for data standards for HIE is probably a concrete foot-in-the-door in this direction.  Effective HIE data standards should create a backward pressure upon product data constructs in a manner that will drop the complexity (and cost) of migrating patient data between products.

  • http://pulse.yahoo.com/_ZNE5BQXLXFP6LWG3QOGPLO4FB4 JoeR

    Are you kidding me?  Here is a better analogy – There is a medical device that has no proof it works, most proof is equivocal and there are numerous anecdotal reports of harming patients.  This device costs a lot of money to buy and slows down your practice.  Finally, you have no realistic budget for maintenance.

    Would you buy into that?

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

      What do you mean by “it works”? What are the expectations?
      It’s a documentation and information management tool. We used to manage information on paper and now we manage information on computers. The transition is difficult, just like all transitions to new ways of doing things are difficult, particularly for those accustomed to the previous ways.
      I have recently interviewed a PCP who has been using a DOS EMR since 1995. It’s not slowing him down. It takes him 1 minute do do a visit note, but strangely enough he is terrified of switching to a new EMR that is not DOS based. Go figure.

      The device, by the way, does not have to cost a lot of money. Some are very cheap and some are practically free.

      Yes, I would buy into that, after doing solid research and finding something I can live with, because lots of people buy into stuff they are not 100% happy with if those are the costs of doing business.

      As an aside, I fully support FDA supervision of EHRs.

  • Anonymous

    “…….medicine is a physical interaction and the human brain can only realistically do one thing at a time. You fool yourself into thinking that you can listen, empathize and be compassionate while at the time type and double click all the right boxes in an EMR system. So invariably, current EMRs will slow us down….at a time when there is even less time to see a patient. Do yourself a favor and wait till the right EMR comes out. The current generation is nice on the backend but has no place in front of a patient.”Edit
    Reply

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

      First, there should be more time to devote to each patient. The shortage of time is not a software issue; it is a systemic issue, much like the billing and documentation requirements are.
      Second, waiting for the invisible EHR is certainly an option, but if I had to venture a guess, I would say that most of those in active practice today will have long retired by the time it makes its appearance.
      Third, just because the boxes are there, it doesn’t mean you have to click them.

      • Anonymous

        I never said shortage of time was a software issue but it is a present and real problem that has NOT been solved. Every “it is good for the patient” endeavor we have embarked on in the last two decades has consistently done only one thing…decrease face time with patients. EHR is just another one.
        Secondly, if you know anything about technology, it is making quantum leaps every year. So I completely disagree that we will not see the ideal one in our lifetime. The only thing that will happen when it arrives is that the hospitals/doctors too impatient to wait will stick to their antiquated overpriced systems and ensure that we still will not have the interoperability that EHRs are supposed to provide. 

        “Third, just because the boxes are there, it doesn’t mean you have to click them” I honestly have no idea what you mean by that. These systems have all have required boxes that you must check/click/fill before moving to the next step. 

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

          I would question those who argue that EMR is good for the patient. It may have some upsides, but I do agree with you that downsides currently outweigh the benefits to individual patients. This however is due to a system that is concerned with billing, and more recently with managing populations in the abstract. Any software, other than something along the lines you describe in your first comment would constitute an impediment.
          Yes technology is advancing by leaps and bounds, but there is a business imperative forming, that if ignored may put you out of business before the perfect technology comes along.

          As to the click boxes, out of the box so to speak, there is no requirement to, say, click on every normal or abnormal finding in an exam template. In larger facilities, administrators frequently configure EMRs to require clicking on enough boxes to justify higher billing codes. This again is a systemic issue and not due to software per se. Since this post was aimed at small independent practices, this should not be an issue for them.

          • Anonymous

            Good doctor is more important than a good EHR.

            Sad in large bureaucratic constructs (like my state’s mental health system) to see how central management attempts to create good care with algorithms, required fields and radio buttons.  It amounts to requiring everybody in the auditorium to wear identical suits … size, color, tailoring.

            The problem?  Trying to create better clinical quality among the caliber of clinicians willing to accept the wages that were being offered.

            The algorithm has been abandoned.  There aren’t sufficient resources to keep it updated, and the original version was tainted by the influence of the pharmaceutical industry.

            The forced fields and radio buttons?  We know those aren’t for the patients’ sake, or the clinicians’ sake as we shake our heads to navigate them when they have no application to our patient at hand.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    From docs I have talked with, the CMS’s $44 000 just covers implementation. There does not seem to be any profit from this source.

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

      The CMS $44,000 is spread out over 5 years, so the practice has to come up with the cash upfront and hope that ongoing maintenance will be covered by the yearly MU checks. Not to mention that this is taxable income, so it’s not quite $44,000.
      Basically the incentives are better than nothing, but should not be the sole reason for buying an EHR.

  • Anonymous

    Article paints a grim analogy that wouldn’t help to recruit anybody into medical school.
     
    It generates for me a picture of non-clinicians holding clinicians’ noses to pour a bottle of castor oil down our gullets “for our own good.”
     
    The push to EHRs is administrative-politicobureaucratic, and does not derive substantially from the end-users themselves - physicians and other providers.  Why?  We don’t need an EHR to provide high quality clinical care.  We never have.  
     
    By contrast, we have spontaneously adopted smart phones en masse because the benefit/cost ratio is high.  Not true for EHRs at this time.
     
    Re: “Just like you cannot postpone your cancer treatment until the doctor from Star Trek figures it all out, you cannot postpone transition to EHR until EHRs are “ready for prime time”. “  Analogies are imperfect, else they wouldn’t be analogies.  
     
    Non-clinicians want us using EHRs before they are “ready for prime time.”  Clinicians don’t share that desire.  Cannot postpone the treatment?  Yes, we can.
     
    If I choose to continue to see Medicare patients without an EHR, the punitive drop in reimbursement will be offset by the drop in income I would see anyway WITH an EHR.  The high total cost of EHR ownership plus productivity loss currently inherent to EHR technologies cause me to shrug my shoulders about the reimbursement loss and adds one more reason to want to stop accepting reimbursement from such an intrusive third party payer.  Quietly, docs are asking themselves why they continue to accept Medicare.  This adds power to that question.
     
    I’d rather postpone adoption until the technology matures enough to be a low maintenance, low expense, intuitive, easy to use, value-added part of my workflow. 
     
    My capacity to provide solid clinical services does not magically evaporate because I choose to wait for this product to be market ready.

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

      Ultimately, the decision is yours, and yours alone if you are in independent practice. The point I was trying to make here is that deciding to stay on paper may be detrimental to your health at this juncture. Not because EMRs have anything to do with your capacity to provide solid clinical services, I don’t believe they do, but because the bureaucrats in charge of health care decided that EMRs are necessary, just like they decided that ICD-10 are necessary, for no rhyme or reason.
      You may think this is a Medicare only issue, but it isn’t. Private payers are fully on board with extracting clinical data from your practice as best they can, and they are following Medicare’s lead.
      You may like it, or you may not like it, I certainly don’t, but population and risk management are being pushed to the front, presumably in order to reduce costs. Taking good care of individual patients one at a time is not enough any more.
      There is a very pertinent JAMA article this month, which makes you want to tear your hair out, but that’s what it is. http://jama.ama-assn.org/content/early/2012/01/25/jama.2012.119.full?etoc

      There really is not much time to wait around for that perfect EMR, which may or may not materialize. I am just the messenger here. Decisions are made elsewhere.

      • Anonymous

        You are correct.  Gnashing my teeth at you accomplishes nothing.

        A group of HS students interested in medicine came to our hospital today to get a taste of our world.  I worked to stay somewhat upbeat and encouraging.  It took work. 
        Still, I had to mention that this generation of docs faces different challenges from those a generation or two ago.

        And bless my 13 year old son. He’s decided he wants to be a physician.  I take comfort in his tender age … plenty of time to change his mind.  I work to not actively sour him, or to encourage him for that matter.  I simply mention repeatedly that the practice of medicine has changed a lot over the years.  An incredible number of fingers now intrude into a physician’s practice day – and precious few of them belong to physicians.

        Marcus Welby, M.D. is dead.

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

          I refuse to believe that. My daughter is going the same route as your son, but she’s already in college, so if nothing else, I’m fighting for her.
          Marcus Welby is going through a rough patch. He can survive though, if he plays his cards right. I met one yesterday. He sees 90% Medicaid patients and won’t have it any other way. No money for fancy EMR, or anything else for that matter. There are options out there and I will get him on a government sanctioned EMR, because if I don’t, he will eventually be herded into employment and see whoever they tell him to see and charge whatever they charge on his behalf, and he will not be happy and his current patients will have no doctor. So we’ll play the cards we have and hopefully outlast the house.
          I don’t really care about EMRs. They are just a bunch of lines of code. My mission is to keep as many independent docs independent, for as long as possible, because I think the experts are wrong, and industrial medicine cannot be good for our health or our pocket book, and it is definitely not suitable for my little girl.

          • Anonymous

            “Industrial medicine” – yup.  Dovetails with my observations and experience with “assembly-line widget psychiatry.”  Somewhere along the way my profession decided we could listen faster, rationalizing a remuneration based shift of patient flow – a corner into which we actively helped to paint ourselves with third party payers.

            Lines of computer code … My experience is not at a population level, but it seems the older the computer geek, the more circumspect/realistic that geek is re: the role computers should play in human life.

            Having read many of your posts over time, I find a comforting irony in the qualities you value in your doc – which have not driven him spontaneously into the EHR world.  I resonate.

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

            The way I see it, EMRs can be used to drive you into “industrialized medicine”, or can be turned around and used to maintain viable and autonomous private practice. Considering what’s at stake,  I think it’s worth a try….

          • Anonymous

            Nah … the widget psychiatry issue isn’t an EHR problem. 

            It’s deeper, and the shift thoroughly predates EHR issues.

  • Anonymous

    For those of you who are ANTI EHR/EMR, I challenge you to learn these systems, OR get with an IT company and create one that is Provider Friendly. 

    • Anonymous

      OR quit complaining because technology is here to stay….

    • Anonymous

      You’re obviously very pleased with your EMR. Which one do you use?

    • Anonymous

      I use a bad EHR daily.  It provides constant grist for my pseudo-Luddite mill as I write various posts re: EHRs.

      I don’t have a choice over my EHR, except by changing jobs.  I have no voice in modifying it meaningfully.  At best, my system has an overlarge committee paralyzed into inefficacy by its wranglings over where to place the deck chairs on the Titanic.

      This tale of woe is probably not unique, since most EHR purchases pre-HITECH were made by larger organizations, and not by the clinical end-users.

      • Anonymous

        Overlarge paralyzed committee rearranging Titanic deck chairs.  What a minute. Hey, do you work at my clinic?

        • Anonymous

          :-)

          I wish … That might suggest a more isolated problem.

          Mine’s at a state level.

          The capital city gnomes are thoroughly divorced from our reality.  I don’t think they much care.

          Clinicians are herded, instead, into trivial Titanic deck chair cogitations, which they unfortunately seem to think are actually important.

  • Anonymous

    Great post Margalit.  Thinking about EHRs as a serious and chronic but manageable practice disorder is probably the best approach.  I think EHRs are a muddle and are likely to remain a muddle for years if not decades if not permanently (turning physicians into data-entry clerks would leave most productivity experts scratching their heads), but the war is lost.  We must kowtow.  It will not be the last of our new overlords.

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

      Thanks, buzz. The battle may be lost, but the war is not lost unless you allow it to be lost. EMR is irrelevant. The viability of independent practice is in my opinion the real war, and this must not be lost just because it is somewhat inconvenient to click on some boxes.

  • Anonymous

    EHRs is a no brainer. So, why do so many “health care professionals” have no brains? Because they are not willing to spend the extra money necessary to compete and to attract consumers. The future of small office practices is dire. It takes money to compete with the larger practices. In the future, it’s obvious that the largest practices will take over the market. It’s call “economies of scale”. I’m guessing but maybe Business 101 wasn’t part of medical school training. What really needs to happen, at least to begin to bend the curve on costs for the health care consumer, is for EHRs to roll out at a much faster rate so that the cheapskates who keep fighting it will simply dry up and blow away. The consumer needs to drive this! In fact, we need an Occupy Health Care Movement to drive this! The consumer has been abused and ignored for far too long. It’s time to get the whole topic of health care on social media. It’s time to mobilize and move health care to Occupy Wall Street status. Health care corruption needs to be exposed and opened up to social media. Consumers need to revolt!

  • http://twitter.com/stales Alicia C. Staley

    Do you have a source for this statement: “there are documented instances where patients’ deaths were directly attributed to an EHR.”  I’d like to learn more about this.

  • Anonymous

    Just once I’d like to hear some of you “professionals” talk positive about the tsunami of change that’s coming. I’m talking about the huge changes that are about to steamroll over the health care industry that are coming for one reason and one reason alone. To benefit the consumer. The health care industry has had decades to make things work in favor of the consumer and what have they done? They chose profits and greed over the consumer. They have purposely made health care chaotic and difficult so that more money needs to be spent to sustain it. You did it to yourselves! You brought this tsunami on yourselves. You milked the cow to the point where the cow is on life support. The goose that lays the golden eggs is dead. We have no more to give because you’ve taken everything. 50 million Americans are uninsured and can’t afford to participate. 25 million more are underinsured and don’t know if their insurance will cover them if they get sick. Are you proud of that? You have frightened us for far too long, especially the elderly on Medicare. You should be ashamed. Scaring old people should be a crime! Now, all we hear from you is whining and crying about EHR? Get real, you pompous egotistical shysters!

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