The sad state of EMRs: How they are doing more harm than good

I used to be a big believer in the transformative power of digital data in medicine. In fact, I devoted the past decade of my life to assisting the “movement” towards better record keeping and shared data. It seemed intuitive that breaking down the information silos in healthcare would be the first logical step in establishing price transparency, promoting evidence-based practices, and empowering patients to become more engaged in their care decisions. Unfortunately I was very wrong.

Having now worked with a multitude of electronic medical records systems at hospitals around the country, one thing is certain: they are doing more harm than good. I’m not sure that this will change “once we get the bugs out” because the fundamental flaw is that electronic medical records require data entry and intelligent curation of information, and that becomes an enormous time-suck for physicians. It forces us away from human interaction, thus reducing our patients’ chances of getting a correct diagnosis and sensible treatment plan.

How bad is it? The reality on the ground is that most hospitals are struggling enormously with EMR implementation. There are large gaps in the technology’s ability to handle information transfer, resulting in increased costs in the hundreds of millions of dollars per small hospital system, not to mention the tragically hilarious errors that are introduced into patient records at break neck pace.

At one hospital, the process for discharging a patient requires that the physician type all the discharge summary information into the EMR and then read it into a dictation system so that it can be transcribed by a team in India (cheaper than US transcription service) and returned to the hospital in another part of the EMR. The physician then needs to go into the new document and remove all the typos and errant formatting so that it resembles their original discharge summary note.

In one of my recent notes the Indian transcriptionist misheard my word for “hydrocephalus” and simply entered “syphilis” as the patient’s chief diagnosis. If I hadn’t caught the error with a thorough reading of my reformatted note, who knows how long this inaccurate diagnosis would have followed the poor patient throughout her lifetime of hospital care?

Another hospital has an entire wing of its main building devoted to an IT team. I accidentally discovered their “Star Trek” facility on my way to radiology. Situated in a dark room surrounded by enough flat panel monitors to put a national cable network to shame, about 40 young tech support engineers were furiously working to keep the EMR from crashing on a daily basis — an event which halts all order processing from the ER to the ICU. Ominous reports of the EMR’s instability were piped over the entire hospital PA system, warning staff when they could expect screen freezes and data entry blockages. Doctors and nurses scurried to enter their orders and complete documentation during pauses in the network overhaul. It was like a scene from a futuristic movie where humans are harnessed for work by a centralized computer nexus.

At yet another hospital, EMR-required data entry fields regularly interrupt patient throughput. For example, a patient could not be given their discharge prescriptions without the physician indicating (in the EMR) whether each of them is a tablet or a capsule. As patients and their family members stand by the nursing desk, eager to be discharged home, their physician is furiously reviewing their OTC laxative prescriptions trying to click the correct box so that the computer will allow the transfer of the entire prescription list to the designated pharmacy. When I asked about the insanity of this practice, a helpful IT hospital specialist explained that the “capsule vs tablet” field was required by Allscripts in order to meet interoperability requirements with our hospital’s EMR. This one field requirement probably resulted in hundreds of extra hours of physician time per day throughout the hospital system, without any enhancement in patient care or safety.

For those of you EMR evangelists in Washington, I’d encourage you to take a long, cold look at what’s happening to healthcare on the ground because of these digital data initiatives. My initial enthusiasm has turned to exasperation and near despondency as I spend my days as a copy editor for an Indian transcription service, trying to prevent patients from being labeled as syphilitics while worrying about whether or not the medicine they’re taking is classified as a tablet or a capsule in a system where I may not be able to enter any orders at all if the central tech command is fixing software instability in the Star Trek room.

Val Jones is founder and CEO, Better Health.

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  • Gary Gartner, MD

    Dictation and transcription errors existed before EHR technology and EHRs are not the cause of them. Why blame the EHR for that?

    • guest

      Perhaps because prior to the enormously expensive requirement for EHR implementation, hospitals and other healthcare systems had enough money to pay for local, English-speaking medical transcriptionists?
      Just like anything else, the budget for healthcare is finite. Force hospitals to spend millions on EMR support, and there won’t be funds to maintain the quality of other functions that support adequate care. And if the doctor’s workload is not adjusted to accommodate the increased time required to review and rewrite a low-quality transcription, then a lot of the time it just won’t get done well. You can’t get blood from a stone.

  • Guest

    I’m so glad our Dear Leader thought it a good idea to invest over $7.7 billion taxpayer dollars in EHRs.

    It’s not like there’s anywhere more useful all that money could have been directed to.

    • adh1729

      The money needed to go to the Syrian freedom fighters

  • Tiredoc

    After using EMRs for over a decade, I made the decision this last month to go back to using paper notes and scanning them into my EMR.

    EMRs excel at improving the accuracy of prescriptions. The mandate to list capsule vs. tablet introduces a necessary level of specificity into prescriptions, particularly prescriptions that are sent electronically. I still use the prescription function on my EMR.

    EMRs are good at enforcing specificity in coding as well.

    EMRs are abysmal at any sort of history and physical examination. They generate unreadable notes that say nothing useful whatsoever. Errors never die, they just live on in the copy function. Patients can be pregnant for years, even the male ones. Amputated limbs grow back, at least according to the physical exams.

    At least as far as I can tell, EMR’s aren’t even useful at cutting down on the amount of paper I burn through.

    • Trina

      My mom is trying to cure her prostate cancer… by getting whoever accidentally entered it into her EMR to un-enter it! But it just won’t die, it gets cut & pasted everywhere!

      • Tiredoc

        I have a few VA patients that regularly get prescriptions in the mail for Simvastatin, Pravastatin and Lipitor, immortal legacy prescriptio s. He only takes Lipitor.

    • heartdoc345

      And my residents’ notes always end up listing the most recent vent settings, never mind that the patient was extubated 2 weeks ago!

  • Ron Smith

    Tools written by non-providers for providers is the problem. My own software that I developed and implemented in my private Pediatric practice works great, is fast, and is designed for provider ease and accuracy. Not only that, the efficiencies it addresses saves probably $75,000+ a year, but I’ve never seen my techniques employed in any other EMR solutions.

    Been programming databases since about 1985 or so. Why aren’t software companies looking at physicians with database development skills is probably a better question to ask.

    Ron Smith, MD
    www (dot) ronsmithmd (dot) com

    • Luscious868

      You hit the nail right on the head. You’ve got software developers who don’t have enough real world experience to know what works and what doesn’t. It happens across all industries. The issue is so many who haven’t had to implement EHR having to do so all at once. There are good software packages and bad, some that are a good fit in certain scenarios and a bad fit in others and as with any software you need the right kind of implementation, training and an IT staff capable of amounting the system.

  • Paul

    If EHRs were a good idea, they would be spontaneously adopted. The fact that the government is trying so hard, by incentives and penalties, to have this technology adopted, should give any prudent physician pause. The idea that a system as complex as healthcare can be “managed” by any one entity is inherently flawed.

    See Thomas Sowell’s “The Vision of the Annointed”. The law of unintended consequences is also rearing its ugly head. Just how big a disaster this will be remains to be seen.

    • buzzkillerjsmith

      Precisely. If they worked in the outpatient setting, independent docs would be lining up to buy them. Since they are not doing so, it can be inferred that they do not work. The analysis really is that simple.

      The analysis in hospitals is different. Hospital execs, like most businessmen, exhibit herd behavior. Even if they realize EHRs are crap they’ll still adopt them because everyone else is doing so. Also, they naturally enjoy new endeavors, even if those endeavors are useless or counterproductive, because then they can look as if they are doing productive work and they can take a break from the mindless grind of actually running a hospital. Add that to the fact that execs do not have to actually use these machines and you know the outcome.

      Those physicians who advocate the EHR mandate are either deluded, bought off, or both.

      I have no problem with independent docs adopting EHRs if they wish to do so.

  • southerndoc1

    If a physician realizes that they’ve become “a big believer in the transformative power of” something, they need to pour themselves a stiff drink, take a couple of deep breaths, and do a little self-analysis.

  • morebuzzkills

    Excellent article, excellent comments. I’m just waiting for the day when the enterprising PCP’s throw up their hands and decide to no longer be in the business of filing insurance and fighting the laughable EHR/documentation battle. Imagine the patient complaints when they start having to file their own insurance! Interesting times await health care if it continues on its current course.

    • Jess

      How did doctors ever get sucked into all this paperwork anyway, when dentists and vets have largely managed to avoid it?

      • morebuzzkills

        Easy, most dentists and vets don’t take insurance.

        • Jess

          Right. So if I want my dental plan or my pet-med plan to reimburse me for any expenses, *I* have to fill in the forms and send them in. So how did doctors get suckered into being de facto insurance file-clerks?

          • morebuzzkills

            It started out as a service to the patient. Doctors would bill the patient’s insurance so that the ailing patient would not have to be burdened with such a task. Like many services, it grew to be expected, and now most patients don’t even consider it a service…it is a right. I suspect that most patients would “long for the good old days when those evil doctors actually billed your insurance for you” if they were ever faced with the nightmare of filing their own insurance.

        • blancheknott

          It’s not that Dentists don’t take insurance, but dental care traditionally has not been covered by Kaiser or other “comprehensive” medical plans. I don’t think it is covered by the ACA [Obamacare], either.
          The great value in EHRs to the government is that they rapidly provide electronic statistics [correct or not], which drive policy decisions which determine how resources [your tax $$$] will be allocated. And as we all know, Garbage In, Garbage Out!

  • jpsoule@hotmail.com

    Watch for this one. I sent one of my elderly CHF patients home with a local home health agency.

    Seeing her in the office 2 weeks later I reviewed her computer generate medication list.

    To my horror and great chagrin the metolazone I had ordered on discharge had some how been changed to methimazole.

    The home health agency was poisoning my patient.
    And there was my signature on the multiple pages of their medicare required paperwork that no one has time to read.

  • blancheknott

    If women are being listed as having prostate CA and men as having endometriosis, that sort of blows the data base for disease prevalence on which we base our “best practices” all to hell, doesn’t it?
    After being my HMO for over 25 years, thru several surgeries, Kaiser has suddenly informed me I have diabetes. At least my “medical records indicate you have diabetes”. I don’t have diabetes, pre-diabetes, or any risk factors for diabetes. No one in my family has ever had diabetes, not even my 92 year old uncle nor my grandparents who died in their 80s. My PCP tells me she cannot remove this data in my medical record, because she didn’t put it in there. Yet she is listed as being in charge of EHR Implementation. We have truly entered a Dark Ages of medical data banking.

    • Annie

      Now imagine that your in-alterable universal health record falsely lists you as having something with even more stigma attached: say, a mental illness or a sexually transmitted disease.

      Every doctor you ever see, every hospital you’re ever treated at, every insurance company, even random workers at the IRS, for the rest of your life, will be presented with that.

      Nice, huh?

      • MabelMabel

        You make excellent points, especially as mental health diagnoses (etc.) still carry a stigma. Imagine what corporations can do with such data. How much would a life insurance company charge someone if the company knew the insured had suicidal ideation 10 years ago? What political mischief could be wreaked if a politician leaked (or threatened to leak) that her opponent had a history of getting traditional talk therapy? Or took antipsychotic medicine? What if someone wanted to defame or embarrass someone?

        • Guest

          There have been reports lately of concierge doctors who let their cash patients use fake names, specifically to keep their names and medical histories off EMRs and government databases. Lots of bloodwork sent out under pseudonyms.

          It’s like a return to the days of speak-easies. Black market medicine. But only the rich will have the means to protect their privacy.

      • heartdoc345

        One of my interns mentioned (truthfully) in a patients social history a whole paragraph about the patient’s father repeatedly raping her as a child. And of course that autopopulated into her daily notes… you know, to maximize billing

  • Tiredoc

    I think the current crop of programs qualifies as “sadistic health IT.”

  • Kari Ulrich

    Must read for every patient! Be informed of the reality of what your doctor is focusing on during your visit. Blame administration not your doctor.

  • MedJ

    The problem doesn’t lie with the idea/concept of EHRs. It lies with a combination of several -human- factors that work together against an effective implementation of the system.

    First of all: it’s impossible to speak of “the system” as one entity. Instead of all hospitals banding together to create one working, interacting system (I’m not even talking about linking it), a myriad of systems have sprung up. Everyone has their own ideas and creates their own programs, which is a highly inefficient way of going about things. Add rules and regulations into the mix (such as the capsule vs. tablet story above) and what you have is one jumbled bunch of systems. But hey: we’d need a world pretty close to perfect for everyone to realise this and work together, right?

    Second: at the moment the (reducing) majority of medical professionals are just not able to properly work with electronic systems. They do not see the logic, continuously yearn for the “good ol’ ” paper world (with illegible, hieroglyphic handwriting) and are all but unable to learn how to deal with these new technologies.

    Third: As mentioned in another comment, the systems are designed by non-providers, for providers. IT-specialists and medical professionals have a vastly different view of things and simply do not know each others worlds/capabilities/logic.

    Fourth and last: as technology becomes faster and more capable, I personally believe we will eventually begin to see a decline in time required for administrative (and related) tasks. Imagine perfect (mind: I said “imagine”) speech-to-text dictation systems, for one. The whole issue with local or outsourced transcription services would simply cease to exist. I wish I had a timeframe for these developments but again I, personally, have excellent hopes that we will eventually get there.

    I realise that the current system has many, many faults and in many cases is more hampering than helpful, but I felt that at least some form of positive view was in order in this topic. It can be done, the question is when.

    • Michaelm

      I agree with MedJ, above. A thoughtful analysis like this without any sort of solution proposed is not very useful. Do you suggest going back to paper? Even if possible, it won’t happen. Yet you seem to rule out “fixing” the problem.
      In truth, computerization brings problems in many fields. (Simple suggestion: try reading for typos and meaning on a computer versus print-out.) It’s not going away. If visionaries with in-the-trenches experience such as on this list don’t suggest solutions, but merely complain, then we might as well be on cable news. Suggestions?

  • heartdoc345

    Cerner sucks. Who’s with me?

  • Guest

    These are the same complsints you always here when adopting new software systems. There are bad systems and good systems and some that very from very good to bad depending on the situation in which they are used and how they are implemented and configured. There will always be loud complaints when those who have never had to do data entry as a part of thier job are forced to do it but at the end of the day once a good package is properly implemented and maintained by well trained IT staff overall operations will be smoother as a whole and there will be cost savings for all involved even if you have to spend more time documenting things than you’d like to. What’s good for the whole isn’t always convenient for some of the individual parts and I’m sure there are many examples where the powers that be picked the wrong software or didn’t configure it right out of the gate. That happens and it will sort itself out in time.

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