Why this doctor loves her EHR

There is a recent and interesting piece in the Wall Street Journal by an orthopedic surgeon, Dr. Craviotto, about the maddening aspect of forced mandates and bureaucratic requirements in medicine that seem to have very little to do with actual medical care and more about hoops through which we must jump that seemingly lead to nowhere.

While I do find the bureaucracy of medicine in the United States insane versus the Canadian system, I was interested in Dr. Craviotto’s take on the burden of the forced electronic health record (EHR) mandate and the time that doctors spend filling out “unnecessary fields” to satisfy regulatory measures. Dr. Craviotto writes that his isn’t an unique complaint, quoting a study commissioned by the American Medical Association that identified, “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”

I am just going to have to stand up and say I love my electronic health records. Really. I really do. I’d like to give the perspective of an early adopted from a fully integrated system.

First of all, I don’t find electronic charting more cumbersome than traditional notes by hand. I can dictate with my voice recognition system or type. I have to write something regardless, so I don’t understand how EHR makes that worse unless of course the few chicken scratches jotted down while talking with the patient was actually the note? Back in the bad old days of paper charts there were many times I’d look for a colleague’s note and find 3 lines, 2 of which I couldn’t read. If the note were dictated it was usually complete, but very often handwritten notes were the norm (and incredibly short and less than adequate, legibility issues aside). I have probably been guilty of that myself. Perhaps EHR encourages doctors to write a little bit more? I’m not sure how that’s a bad thing unless you get carried away and contribute to chart bloat.

Then there is the fact that I always have the patient’s record. I estimate back in the day of traditional charting that I was missing 10-30% of the charts each clinic day. Not having the patient’s information is so incredibly cumbersome and I do believe it impacts care. I have struggled incessantly trying to piece together a previous physician’s plan or to figure out what actually happened in the emergency room more times than I can remember with paper charts. How many times have I ordered a test because I just couldn’t find the result (maybe the lab forgot to draw it or maybe they couldn’t read what I wrote?) only to find some rogue slip of a lab result that was incorrectly filed two days later. Now, I order my lab tests in the EHR, the lab generates the label from the order so nothing ever gets lost in translation, and the results load immediately into the system and then directly into my inbox.

Outside records? They get scanned in, but as more and more systems come online I can link with them.  Imagine the freedom of not having to send those record release forms that seem to never, ever get answered!?

What about prescriptions? My system is fully integrated with pharmacy. Many patients can’t remember their medications or doses. With EHR they’re right there. Some patients tell me they took the medication that I prescribed, but looking at the EHR sometimes I find they did not so then we can talk about how and why that happened. Consider the following scenario:

Me: “What kind of estrogen did you try Mrs. Smith? The cream, the tablet, or the ring?”

Mrs. Smith: “Oh, I don’t know doctor it was so long ago, but whatever it was really irritating so I’d like  something else.”

Instead of taking a guess and potentially having the patient buy an expensive medication she doesn’t want to use or call the pharmacy (if she can remember which pharmacy she used back then) to see if they can possibly track down what Mrs. Smith had in 2006, 2007, or 2008 (she thinks) and then me or my nurse calling Mrs. Smith back the next day if we get the answer, I simply click the medication tab, wait 5-10 seconds while all the previous meds load, organize by alphabet, and there it is. She tried Premarin cream in 2005 so now I can give her something else. Today. Three clicks and 30 seconds of work instead of three phone calls (me calling the pharmacy, them calling me back, and then me calling Mrs. Smith) that still may not gather the right information.

Not only is everything at my finger tips (including radiology images and labs), but the e-mails that my  patients can send me through EHR are also there as well as the attachments that they can send. With a couple of clicks and about a minute to load the image I can reassure the patient that the “cyst” on her ovary that she was worrying so much about is 4cm and simple and so not a cancer concern. I can also reframe my discussion of my patient’s report of not having diabetes with her previous HgBA1C of 8%.

What do I find cumbersome? Well, at the beginning it was very new and change is hard. However, I am one of the minority of doctors who has been using EHR exclusively for over 7 years so I’m pretty facile now (and I’m no computer whiz, IT cringes when I call). I also have access to doctors who are computer gurus who routine share tips and tricks as well as tech experts whose sole job is to help me use my EHR better.

What about the coding and things that are part of the Medicare requirements? I had to code before EHR. That entailed a large sheet with columns of codes and I had to circle each one and then write the ones in by hand that were not there. To find the ones not listed I either had to call my coder or do an Internet search. Now, I just type the conditions or symptom into a field and the code pops up.

The only slightly annoying thing to me is the prescribing. Occasionally I forget to click the right pharmacy and then in a panic after the patient leaves I have to make a phone call to get the prescription switched to the right place.

I do get annoyed by the fields I have to fill out that seem completely unrelated to patient care and more about metrics for Medicare, especially given Medicare hasn’t been using those metrics too wisely otherwise how would an opthalmologist in Florida bill Medicare $21 million a year! I would have to do all that Medicare drudgery regardless, so that’s not the fault of my EHR. (Note to Medicare, hope you are investigating that $21 million a year practice.)

Some doctors are such efficient typists they can chart electronically while seeing patients. Might that enter an element of “computer chill” and result in less face-to-face time for the patient? I think it depends on both the doctor and the patient. Some doctors will interact better than others while using technology, but I do think as more and more people become so technology focused that perceptions of electronic charting interference might change. Any office using EHR could easily anonymously survey their patients and find out who feels charting on the computer interferes with the visit and who doesn’t and adjust accordingly.

My children’s pediatrician moves effortlessly between the computer and my kids and doesn’t seem to make it impersonal at all. My kids use computers at school, they use them at home, so why wouldn’t their doctor also use them in the office? They aren’t even learning cursive at school because according to the school no one writes anymore. They get keyboarding skill assignments, not writing practice. Do we really think a 10-year-old who is destined to be a doctor in 15 or so years will be writing much of anything by hand? Will anyone?

At the airport last year one of my kids asked, “What’s that?” It was a paper airplane ticket. The old-fashioned kind. They had no idea that anyone ever did anything else than book electronically. Would anyone of us want to call the airline, wait on hold until you get an agent, book a ticket, and then wait for it in the mail and hope you don’t lose it?

I am not that good of a typist and my notes are typically long so I still takes notes by hand (traditional face-to-face, as it were) in the room and chart later, but I did that before EHR. I have to either look at a paper or a computer screen while I’m seeing a patient, so there is always going to be some kind of charting interference. It’s possible that using a tablet might help take away a barrier that computer screens might generate as, ironically, it is about the size of a clipboard that many doctors (myself included) carry into rooms now on which to write.

I can’t help wonder if most physician complaints with EHRs stem from poor systems, inadequate training and support, or smaller offices and solo practitioners who can’t tap into a larger network to really optimize their EHR.

Should EHRs be mandated? That I don’t know. I think to mandate something you need clear studies to show it saves lives or improves health. It is important to look at the burden on solo practitioners, because different practices will have different challenges. All I know is having complete and legible information up front allows me to give better medical care. EHR hasn’t degraded my clinical documentation, but improved it.

To me paper charts are a puzzle with missing pieces and you just never know if you’re missing a key piece or not.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

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  • Thomas D Guastavino

    The year is 1990. The federal government has made the decision that everyone needs to switch to cell phones. The government claims that landlines are to inefficient and prone to error which may or may not be true. The only thing everyone can agree on that it is much easier for the government to monitor cell phones then landlines. In order to coerce people to switch to cell phones the government first provides bribes, but eventually will fine people for not making the switch. However, in order to get then bribe the users have to follow and document certain guidelines and have to do so within a fixed time frame.
    Cell phone carriers rush in provide the phones. With then rush to make the switch, fundamental errors are made such as different carriers working on different frequencies so some phones won’t communicate with each other, if you can get a signal at all. Worse still, the market is dictated not by what the users may want or need, but how best to meet the criteria to get the bribe. Phones are made with a 25 digit keyboard so required codes can be entered. Before each call can be made a pop-up question screen appears so that the user can meet the requirements the government has decided are necessary to make the call.
    Congradulations on finding an EHR you love. I suspect you are the exception rather then the rule.

  • buzzkillerjsmith

    “I think to mandate something you need clear tudies to show it saves lives or improves health.” Yup.

    If you like your EHR you should use it.

    Next case.

  • Acountrydoctorwrites

    It doesn’t sound like your EMR requires structured data entry with all your talk about typing or voice recognition. You don’t have checkboxes to describe a patient’s symptoms????
    Tell us the name of your EMR.

    • Jen

      I don’t know what you mean by check boxes for symptoms, so I guess not. I have check boxes for diagnosis. I do my notes free form (typing or with voice recognition).

      • Dr. Drake Ramoray

        I can’t fathom this method meeting any sort of meaningful use or PQRS requirement. I agree, I’m interested in what EMR you are using. As of right now I suspect it may be a real functional EMR that isn’t wha tmost of us think of when soemone says EMR (Cerner, Epic, etc.). I could probably grow to love an electronic record too if I removed all the beuracratic BS that comes with them.

        • Jen

          I use Epic

          • Dr. Drake Ramoray

            Then I respectively request some of whatever you are smoking. :)

          • guest

            You use EPIC? And you don’t have check boxes?? I am on EPIC and it’s lousy with check boxes, ones that you need to check twice so they stay checked.

      • Acountrydoctorwrites

        Think Color by Numbers versus painting from the heart. Choose only between crushing and squeezing chest pain. Describe clinical findings by clicking the box that best matches what you see. That is structured data entry, easily searchable compared with free text where doctors can describe size as “plum sized” instead of in centimeters. Imagine writing your memoirs from drop down menus.

  • Chiked

    “My children’s pediatrician moves effortlessly between the computer and my kids and doesn’t seem to make it impersonal at all”

    Really? If that works so well, how come all the other health professions aren’t dragging computers to the bedside. Went to the dentist last week and my kids had my dentist’s undivided attention. The week before then my youngest needed her hearing checked. No EHR there.

    Face it doctors lowered the standard years ago and now patients can’t even tell there is an elephant in the room.

    • Lisa

      Other health professions use computers. My dentist uses a computerized record. He can down load x rays to the record and keeps treatment records on it. It is not at all distracting and I still have his undivided attention when he is cleaning my teeth (he doesn’t use a hygienist). My optometrist also uses a computerized record system. Again it is not distracting. My podiatrist uses an EHR. I like the fact that he dictates his notes while I am listening, because it gives me a chance to make sure we are on the same page. My lymphedema therapist enters histories and notes into an EHR. I don’t find it distracting; she would either be entering data into a paper chart or into the computer.

      Last time I saw my pcp, he didn’t bring his computer into the exam room. I wanted specific information about a test result – he had to leave the room and get his computer. He has brought his computer into the exam room on other visits. I think he is still trying to figure out how integrate it.

      My first oncologist used paper charts. He spent a lot of time leafing through my chart to find information. After he retired, I began seeing a younger oncologist in the same practice. She uses an EHR. I notice she doesn’t spend much time going through my record to find information. Most of her time with me is spent asking me about any symptoms and on a physical exam. She usually updates the EHR at the end of the visit. It isn’t intrusive.

      From my point of view as a patient an EHR in the exam room is not a big deal.

      • Chiked

        There is a big difference between providers using computers and providers using computers while examining or treating a patient. You may find it reassuring but maybe your time isn’t that precious. I expect every second of my 15mins in the doctor’s office to be spent on ME. Why? Because the human brain cannot yet parallel process. I derive comfort from knowing that every bit of information being collected or given to me is done with their undivided attention.

        • Lisa

          While your doctors many be collecting information from you with their undivided attention, I wonder how long it is retained and if it is accurately recorded.

          Doctors used to walk into the esam room holding my chart. They made notes in the chart during an office visit. Now the notes are made electronically. I just don’t see the diference bwtwen making making notes electronically and on paper.

          • Jen

            You have to chart regardless. I couldn’t possibly remember everything my patients tell me otherwise. I have to look at a piece of paper to write or look at a computer. Some doctors make both look like they are disinterested, so I think that some is personal communication skills. I also wonder if you hate your EHR if that will show in how your use the interface.

          • Lisa

            I also wonder if some of the angst over the use of EHRs is generational.

          • Jen

            I wonder to, although I am 47 and not the most tech savvy person around.

          • Chiked

            Nope….In fact I find people who go gush over EHRs are usually the unsophisticated electronic types who don’t know much about how computers work. Ask any physician who can code and they will tell you the current EHRs are pathetic.

          • southerndoc1

            Generational in the same way as texting while driving is generational?

          • Lisa

            I wasn’t aware that testing while driving is generational. I think that is related to a lack of any thing resembling common sense….

          • Chiked

            There is an ocean of a difference between writing on a piece of paper and charting in an EHR. You will not remember a thing your patient says for every minute you chart in a computer. For me that is unacceptable.

            Now if they made my appointments longer, I may not be so averse to it. So far I have not seen that. It is the same amount of time as before, except split between you and a computer and who knows what next.

          • Jen

            I actually write my notes on paper and then chart later, however, my point is that I have experienced clinicians who are able to chart on the computer and it didn’t seem to affect the experience.

          • SarahJ89

            I’ve seen a huge difference. I never saw the top of my doctor’s head before EHR. Now it’s all I see. I’m jealous or her laptop–it gets way more attention than I can ever hope for now.

          • Chiked

            Again, I have no problems with electronic notes. Just don’t make your notes while pretending to listen to me. It is impossible do both.

          • DeceasedMD1

            the medical record hasbeen pretty much destroyed with ehr’s. it has tampered with the MD note so much that it lacks the information necessary to undersatnd the consult.

          • Lisa

            I don’t know how to evaluate your statement.

            I think a medical record is much more than an MD note. It is the pathology report (and the actual scans or xrays). It is the surgical reports. it is the test results. It is a record of prescription and of treatments.

            Is the only purpose of a medical record to transmit information regarding a consult?

          • DeceasedMD1

            the purpose of a medical record is to make sense of the data, besides storing scans and prescriptions. Any MD should be able to read another docs notes and undrstand what occurred during the evaluation. That has been completely undermined with EHR’s.

    • Jen

      I don’t know why other providers are not able to use the computer as effortlessly as my pediatrician. We have been using EHR exclusively for 7 years that might be part of it.

      • Chiked

        Your success on an EHR has little to do with what you feel but how your patients feel. Ask your sick patients if it seemed like you were so terrific now that you spent more of their face time on a computer.

        • Jen

          I believe I mentioned in my post that I still take notes by hand in the room, so your point about the computer interfering doesn’t even apply to me. My EHR helps me figure out how to prep best for my patient (i.e. having all of her information) and help me integrate her care afterwards. I fail to see how that is bad.

          • Chiked

            I am referring to your pediatrician and other providers who define success from their point of view.

          • guest

            It might matter that 99% of pediatrician’s patients are healthy. Generally not a very sick population requiring a whole lot.

  • John C. Key MD

    It’s not the EHR that bugs me. It is taking direction from non-medical IT staff that may be nice people but don’t understand how our world works. Every couple of months our organization gets an “upgrade” to our EMR which (1)always adds more keystrokes (2) has nothing to do with documenting clinical observations and (3) allows audits of various minor jots-and-tittles of the chart content. I wish our upgrades would make the EHR more doctor-friendly and relevant for patient care.

    Now, having to keep one’s face glued to the monitor, that’s another issue.

    • Jen

      A lot of the upgrades that I have seen are due to State or Federal metrics that need to be recorded. Some I think are institution specific. My point is be careful what you blame the EHR for and what you blame on non-EHR mandated metrics that you would be forced to capture regardless.

      We also get a lot of internal upgrades, but to me the nuisance is in the change. In a day or so it seems just fine. Many of our upgrades are also very useful shortcuts. We have doctors who are so computer savvy that they identify issues and then write code to make it better. When th person writing the code also uses the system it helps a lot!