Explaining the epic failure of EMRs

Explaining the epic failure of EMRs

It is no news a lot of doctors like to stick up a rather snotty nose to EMR. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia, and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there.

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS), I complained to the IT guy that the thing barely works! The guy was sympathetic and said, “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs.”

But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with,” he retorted. “Computer records do take a longer time than paper, and there is nothing I can do to change that.”

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. Add to that the inertia people have about their old ways and you have a deal breaker right there.

That’s not all. Driven by the constant government whip to adopt EMR, and an EMR industry that is hell bent upon imposing itself on healthcare, a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.The constant juggling not only made the patient encounters time consuming and cumbersome, it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.

What’s wrong with the current adoption of EMR? Why are even the converted like me questioning EMR?

I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. Second how the EMR tries to impose its will on to us instead of the other way around. A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty. It is a common experience that most people find dictating their notes much faster than typing them. Accurate automated transcribers could really speed up record keeping, thereby selling EMR to the unconverted while saving costs over manual transcription.

On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes 10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better, but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper.

Trying to impose a ready made architecture on to health care will not work. “It works for retail and banking,” some people seem to offer cluelessly. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they force things you to do things you wouldn’t otherwise do.

Such forced behavior modification may make the administrator, the insurance company, and the government happy but I can’t understand how selecting a dozen pesky radio buttons while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamored with the EMR, just because the government said so, or that it made the IT companies a few million dollars richer.

Kiran Raj Pandey is an internal medicine resident who blogs at page59.

Image credit: Shutterstock.com

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  • http://twitter.com/cooperberg_ucsf Matt Cooperberg, MD

    I assume your choice of “Epic” is hardly coincidence!

  • http://twitter.com/MeridienHealth Meridien Healthcare

    If these systems didn’t cost the earth, then perhaps we wouldn’t be so critical – if they were reasonably priced, then no one would mind a few hiccups along the way.

  • southerndoc1

    Face the facts: the experience of docs and nurses using EMRs is completely irrelevant to the forces that are driving medicine these days.

    • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

      EMRs were never about improved efficiency of physicians or improved care of patients. They were developed and ARE being implemented to improve the speed and level of billings.
      It always makes me chuckle to hear a policy wonk taut EMRs as improving patient safety. All it has done in my hospital is to make it harder to track errors. There is SO MUCH crap and information flowing through the EMr that most of it gets missed or just flat out ignored. When things dont get done or missed and errors made…. well, everyone just throws up their hands and says “wasnt my fault” or “I dont know, I never saw that order.”

  • Sarah Kohl

    The three problems I see are an interface which doesn’t reflect work flow, the inability for EHRs currently on the market to ‘talk’ to each other, and the enormous amount of time needed to complete simple tasks. EHRs are databases–they can add value but only if they solve problems of the end user not create problems. Surely applying simple user interface principles could sovle a lot of the problems. Develpoing transfer protocols whereby data can be shared between systems, and populating data fields in a meaningful way can be done too. Anyone remember how revolutionary the ‘http’ was and how it allowed sharing of info/websites on internet? Lastly, reclaiming the 2 extra hours of ‘charting’ time caused by slow EHR programs would be welcome too; certianly the code behind the EHRs can be tweaked to improve speed.
    All of the above cost money, and currently there is little incentive for the EHR creators/vendors to improve a product which has already shipped. So we all continue to ‘adapt and overcome’ with workarounds– all the while gnashing our teeth. Doctors are not ‘anti-technology’ but they do know when something doesn’t work. I wonder if we will look back on this time and ask ‘what were we doing?’- the forced early adoption of an unfinished product is painful. I look forward to the day when the muiltiple brands of EHRs I use in the hospitals and offices actually help not hinder my work.

    • southerndoc1

      “EHRs are databases”
      But the end-users are CMS and the large insurers.
      As the data entry clerks (previously referred to as physicians) have demonstrated their willingness to work for free (your 2 extra hours of charting time daily), there’s no reason to waste time or money improving their working conditions.

  • William May

    EMRs make records widely available. This is an improvement over the days of “who has the chart.” However, they were sold as something which would allow easy portability and transmission of medical records. The difficulty is that current systems are proprietary. A hospital using system A cannot transmit to a hospital using system B. The solution is to mandate a common, extensible format for the underlying data all EMR to employ, something like a .doc format for medical records. This would allow proprietary systems to interoperate. And when a hospital decided that system C was better than what they were using, they could reward the company that makes system C. Presently switching systems cannot be any too easy. This proprietary lock-in is at the root of companies failure to innovate.
    You are perfectly correct that data entry is a huge issue. At my hospital, our EMR guru was pushing handwriting recognition as the solution when we adopted system “C” back in 2004. Pen input was, predictably, a miserable failure. Voice recognition could help, but it needs to be integrated into the EMR and….oh, there is that failure of competition to drive innovation again.

  • buzzkillersmith

    1. The the heck does this guy’s first sentence mean?

    2. What’s with the obligatory kowtow to EHRs? Paragraph two: ” The automatisation of medical record keeping is the new way forward.” Then he proceeds give us an excellent argument as to why EHRs, at least as currently designed and implemented, are in fact not the way forward but rather misbegotten technological snafus foisted on us by a combination of irrational technophiles, clueless or bought-off doctors, corporate scumbags and their shills, and government lickspittles who don’t give a damn about anything but meetings, memos, and climbing the greasy pole.

    Young doctor, there is no law prohibiting you from drawing correct conclusions from the evidence. Call it like you see it. You can put all the lipstick you want on this EHR pig and you can name it Monique, but it’s still a pig.

    • southerndoc1

      “Call it like you see it.”
      Something about the Emperor’s new clothes comes to mind . . .

  • Lorraine Bonner

    The EHR converts the analog patient into an extremely inadequately sampled digital format.

  • http://www.facebook.com/jacqui.maurone Jacqui Ballan

    I find the documentation of most doctors and nurses illegible. It’s nice to be able to read what is written. It is also nice to not have to spend half the shift looking for the dang chart.

  • Timothy Justice

    We’re in the middle of our EMR implementation, and currently in the “go live” phase of our POC module. I can see pros and cons of the system, frankly (I’m the IT guy, so I get all of the tomatoes thrown at me!), but I can also see where it will impact physicians’ and nurses’ workflow.

    I agree with the commenter who said, basically, that the problem is that we have to sell the farm to purchase these systems. The analogy I used when we were in the evaluation phase for vendors was that it was the electronic equivalent of putting up a new building (because the price is in the same range, frankly!) and that consideration needed to be geared around that.

    When the dust settles, I think it will improve the quality of care at our small CAH. But nurses with 12 patients on the floor on a busy day won’t see it as negatively as nurses in a 150 bed facility.

  • http://www.facebook.com/beau.ellenbecker Beau Ellenbecker

    EMR’s are in general poorly designed. Very few are use friendly. They do not generally allow easy access to overview data. Also most are designed around data mining so they use database style entry. They would be much more useful if they allowed for free hand entry of preventive data and history.

    Also most EMR’s try to do way to much. Simplicity is what makes apple so successful in technology. EMR’s get more complex with each iteration but not any easier to use. We need a new design from the ground up based on simplicity of data entry rather than on ease of statistical analysis.

    I find at least 3 things on a daily basis I could do to alter my EMR and make it easier to use but unfortunately I don’t have the ability to alter them.

    • southerndoc1

      EMRs are in general very well designed for their intended functions. See my notes below.

  • Ara Deukmedjian MD

    EMRs have three (“true”) purposes:
    1. Slow doctors down. With EMRs doctors definitely see fewer patients. Fewer patients seen = less patient care = less billable services, fewer treatments/persciptions/ordered tests = Better Medical Loss Ratio for Insurance companies = more money/profit for the insurance companies and greater suffering of the sick.
    2. Make it VERY easy for insurers to audit doctors billing and look for “fraud”. Did you all notice during the birth of the EMR a second birth occurred shortly afterward..the “RACS”. PS: RACS posted 50 Billion in “overpayments” for 2012, 10x more than 2011… and they are just warming up. Oh and by the way, the RACS are owned and controlled by private insurance companies as are the Medicare MACs.
    3. Make priveleged investor-owners of EMR companies a whole LOT of money by Medicare (private insurers) mandating implementation of these astronomically expensive databases. I particularly like the whole “Medicare Certified” label. I wounder how many Billions $$$ exchanged hands for those deals…err,.. I mean “endorsements”.

    • margo

      I would add one thing to your brilliant list!! It is a way for insurance companies to easily see patients diagnosis and medications to deny them for preexisting.

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