Today’s EHRs: No doctor left behind

It has been quite a year.  Between 3 main hospitals, 2 major medical institutions and 3 major healthcare networks, our practice has been on 3 different echocardiographic reading platforms, 3 ECG reading platforms, and 8 different electronic health record systems including 4 instances of Epic alone. I am typically enthusiastic to a fault about new technologies and, time after time, have rushed in, often where angels feared to tread.  I have been known to spend hours creating a workflow when it would have taken a fraction of that time to accomplish the task the old fashioned way, clinging to the promise that this initial investment of time and effort would pay dividends in time and simplicity later for myself and my colleagues.

But lately, I am ashamed to say, I am having a change of heart. After watching my colleagues struggle through documentation despite Herculean efforts to get the templates, wording and data fields exactly right, and after watching our nurses click and click and click and, finally, click again just to give us a sense of how the patient is doing, some cracks have appeared in my resolve to make this technology work for us.  I am feeling guilty for trying to document while I am talking to patients and families. I am also feeling guilty for being untrue to the EHR.

I respond to complaints about templates, reports, and workflows. I reassure my colleagues that we are working on these issues, and everything is going to be OK. Once in a while, someone says, “That is so much better than before!”  I like to think they are not just trying to make me feel better. My role is the ever-optimistic evangelist for whatever project is at hand; the interface, the software or the workflow. But, even I am beginning to realize that the new paradigm has not, and likely will not, save the majority of practitioners any significant time. Many feel that it has lengthened our work days and that this will not improve with time.  From experience, I can not refute this.

When I speak to referring practitioners, they thank me for my letter, but we both acknowledge that it is less a consultant’s letter and more a Frankenstein’s monster, constructed from data scavenged from the morass of the larger medical record.  It rehashes things that these referrers already know about the patient, because, well, these are their patients.  It rehashes these things to show insurance reviewers that I considered these pieces of information in my care of this patient.  It rehashes these things to prove that I did my job; something that my referring colleague has already trusted me to do by simply sending me their patient.  Behind this reality is the growing feeling that the old consultant’s letter — short, sweet and personal — is dearly missed.  You know the one: “Dear Bob.  I saw your patient today.  You were worried about this.  I think they have this, and this is what I would do about it.  Thank you.”

As I write my notes, I cannot seem to shake the feeling that we are faced with the choice between getting our work done in a reasonable time and generating a truly accurate medical record where detailed data must be placed in the right fields.  Choosing the former seems to run counter to what we initially set out to accomplish. However, the grand goal of safer patient care does not seem to consider the time constraints of both patient and physician.  To make sure we are moving toward that goal, meaningful use was invoked.  I begin to wonder how patient care is improved by a button that must be clicked, existing only so that my click can be counted?  Again, it serves to prove that we are doing our jobs.  Maybe I am naive, but I like to believe that most of us are providing quality care to the best of our abilities. Is this a requirement because somewhere there is a cache of physicians who need reminding to care for the patient?  Just as stellar students may be tethered by “No Child Left Behind,” in this “No Doctor Left Behind,” we  likewise may be saddled by these reminders; bound to the lowest common denominator.

What are we accomplishing?  Let me be fair. Now, orders are legible.  The correct medication might be given more often.  Medication interactions and allergies may be caught before harm is done.  I would like to think that these improvements are truly happening.  There is great benefit to the EHR that is within our reach.  But, I now wonder if the EHR should be all things to all people?  I recall being in meetings where those tasked with determining how content should be structured for the EHR build had long discussions over how options should be presented to the user and how orders should be routed so that care could be rendered while encounters, billing and inventories could be tracked.

Does the physician really need to see all the stocked preparations of normal saline or every available preparation for prednisolone?  Regardless of my choice in order entry, I have always been confident this is something that the pharmacy knows, and I can trust them to prepare the right dose.  But, what if I click the wrong imaging study, the wrong laboratory test, or I inadvertently order packed red cells in a clinic encounter instead of for the operating room next week?  I can say from experience that, depending on my electronic misstep, I may not obtain the information I want, or the result may not make it to the record, or our surgeon may have his case delayed so that blood can be processed. Have we improved anything for ordering practitioner, diagnostic imaging department, laboratory, surgeon or, most importantly, patient in the new paradigm?

Sadly, I must now admit that I am really not sure.  I would like someone to reassure me that at least one of us is better off now.

Gregory Kurio is a pediatric cardiologist who blogs at When I think about it …

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