Guest Article: Why Doctors Hate Electronic Medical Records

[CC-Conrad Clyburn-MedForeSight]

Colleagues,

Thoughtful and thought provoking.

As advocates of health information technology we need to be mindful of the challenges ahead to intelligently capture the full power that Health IT offers. What follows is an excellent Blog Post from " The Healthcare IT Guy" , Shahid N. Shah. This is an excerpt, please go to the link at the bottom of the page to read the whole post, and to receive its full value ...


... Most of us in the healthcare IT believe the ARRA (stimulus) bill is a Good Thing for the industry in general. Many existing companies will be able to sell more products and many new companies will be formed to create electronic medical records solutions. I was talking to Dr. Bill Cast last week about EMRs and what he and other physicians thought about them in general and I got some great feedback. Dr. Cast is a practicing Otolaryngologist, and is a past member of the AAO Board of Directors and AMA Delegate from Otolaryngology. He has been a lobbyist for the Indiana Malpractice Law and founding Chairman of Dupont Hospital in Fort Wayne, Indiana, a managing partner of his medical practice, and President of several multispecialty ambulatory surgical centers. He was editor of Medical Business Review, an economics newsletter for physicians. He is currently CEO of www.nomoreclipboard.com, a personal health records company. I invited him to share his thoughts about why physicians aren’t in love with EMRs which should form some good input for companies looking for ways of improving their own solutions. Here’s what he had to say... ........


... You may ask what qualifies me to speak. First, I am a physician in a six doctor practice who for eight years has been digital, using a fully-featured EMR. Our old record room is now an employee lounge serving Peet’s Coffee. I live in an Indiana city in which 65% of physicians use some form of EMR in their offices and in which a regional health information exchange serves 95% of all providers. Our two hospital systems have EHRs. I’ve practiced in four states, served in the U.S. Army as a surgeon and have worked intermittently in a VA Hospital over a 6 year period. Lastly, I’m CEO of a personal health records company, a spin-off of an EMR company. And so, I’ve seen lots of software installations and talked to lots of unhappy doctors... ...

... How do we know doctors hate EMRs? Look at anemic adoption rates ... In the business community it is common to hear doctors referred to as computer-phobic and “in denial” about the benefits of computing. That is wonderfully ironic when heard alongside chronic complaints that doctors are overly eager to use expensive technology: lasers, cryro-probes, fiber optics, MRI and PET scanners, stents, and implants. The fact is that doctors love high-tech ... “Why are physicians so recalcitrant to use EMR?” He responded: “They are not recalcitrant; they are in open rebellion! Why? Because the software you give them is garbage.”...

... Physicians know that better exists ... They suspect that if their EHRs and EMRs had physician-specific home page functionality, that they could drop and drag orders, answer FAQs, dictate letters, and save time with templates with many fewer clicks. Ordering medications should be as safe and uncomplicated as using E*Trade ... Today most EHRs and EMRs are invasive both to workflow and finances...

... ... Let me close by saying that the federal software stimulus will be good only if the government standards ultimately endorsed, properly guarantee interoperability and avoid paradoxically funding software that is not only too expensive but that also create silos of proprietary isolation. Properly begun, stimulus is likely to fully return government’s investment through efficiency—not immediately, but over several years. Our office covered EMR acquisition in about 5 years. We did not spend $44,000 per physician. As best stated by M. Lynn Marcus in the MIT, Sloan Management Review, “The Magic Bullet Theory in IT-enabled Transformation,” we confirmed that the key to physician satisfaction is flexible software that does not dictate workflow choices. New software is not the goal; the goal is an information system with a good measure of flexibility. To perfect this system, one will need to reserve a measure of their stimulus funds for training, equipment and employee re-tasking. The good news is that after a period of adjustment to accommodate differing practice styles, one creates a shrinking record room, no piled charts, and fewer employees or employee hours spent finding, pulling and re-filing records. And one finds many unexpected conveniences. One cannot put a price on taking call from one’s home with rapid web-based access to the patient’s office chart at 2 AM. ...

Read on at: http://www.healthcareguy.com/index.php/archives/663

ENJOY!

CC

[John A. Liebert, MD]

While doing ten years of locums work in 50 different clinical sites from coast to coast, I also have had the opportunity to work on most major vendor EMRs, plus, last summer, AHLTA, the Army's EHR. All but one of these were literally sold to hospital IT departments with cursory buy-ins - if that is what you call a lunch meeting with dog and pony show from vendor medical consultants. (You never see them again, when the systems don't work right.) One system I did find helpful, but was homemade to serve 40 clinical sites spread across a large region; they had hundreds of technicians to keep it up and running. It worked, and I learned pretty fast how to use it. But, no way would this IT deparment claim that it prevented me from making any fatal medical mistakes or save money from my productivity. It worked for them, because it was interoperable between multiple sites, and doctors hired programmers and developers to build it. Then, they made sure it worked - not just most of the time, but also on Saturday nights, just in case a stat lab required computer order entry. There are a lot of testimonials about "Lean Managed Health Care" today, most of which focus on efficiencies of EMR or EHR. Finding myself aggravated by these testimonials, I started researching Lean Engineering, only to find it is synonymous with The Toyota Way. I then published a paper in the King County Medical Society Bulletin, superimposing the rules of Toyota Way Management to computer driven patient Throughput. Rebellion is the right word, because none of these costly installations are going to work without participation from critical constituency groups controlling patient care and throughput; that is really The Toyota Way! Pharmacy, Lab, Hospitalists, ER, Security, Finance, Admin etc all have to be at the table. it appears to me what happens now is that a vendor sells millions of software installations to IT; that is called "The Hook". Then, hospital/clinic admin is in too deep before realizing there are enormous problems with it; so, the pressure comes down on floor personnel. More training, more overtime - and more costs with billings from vendor for training. All the costs, according to vendor and admin - by now stuck with it - because doctors and nurses need training. There is a literature on this, wherein traditional structural malalignment between administration and clinical staff is actually exacerbated by IT purchases, installations, going live and, finally, just "learning to work with what we have instead of grumbling". The Army has a huge problem on its hands with AHLTA for just this reason; nobody has a clue from where it emanates. It just comes down, adding to the burden of trying to keep up with Force Health Protection, already in crisis, according to weekly headlines. As said, it does not have to be that way. Doctors can, with partnership with their nursing, clinical lab, imaging colleagues etc, build a system that not only works - they can, as the author and I have both learned - work. But, also, an EMR/EHR might actually do what it is supposed to do. That is, reduce fatal medical errors and reduce costs - it's called service optimization. What studies show that any of these vendor systems actually optimize healthcare services? And, more particularly, how does one differentiate testimonials of marketing and governmental lobbying from controlled Clinical IT research? We don't precribe drugs that don't have a research base of safety and effectiveness, but we accept computerized control of our practice and documentation that, to best of my knowledge, has little,if any, research base for either safety or effectiveness. No wonder the rebellion, distorted by propaganda blaming doctors for their lack of computer skills and motivation for change to the information world. I have worked at UCLA Medical Center; the young docs with whom I worked are more computer literate than most hospital IT Staff where I have worked.
John Liebert, MD
President, Expert Clinical Systems, Inc
Phoenix, Arizona

[Stephen C Schimpff]

Dr Shah presents well the issues. Here are some thoughts, largely the same but presented slightly diffently. Most systems are not designed by doctors but by programmers who have little knowledge of how physicians actually work. The result is a system that is cumbersome at best. I toured my former hospital where I was CEO and where we installed a complete EMR in the early 2000s from one of the major vendors. I was told by multiple attendings and the residents that they liked the system highly for order entry, results reporting and reviewing images. But they would not use it for history, physicals or progress notes. Why? "Too hard to use."
The big vendors need to figure this out but so far they have not. They know the problem exists but as a CIO of a major academic medical center said to me "the docs just need to learn to use the new systems - stop being so old fashioned." At first I tended to agree with him but I soon learned that the problem is with him and his colleagues - they need to learn how physicians work so that they can develop systems that are functional and do not reduce productivity.
At the risk of being commercial, I am aware of a company that went about this much diffrently. Salar, Inc in Baltimore went to Johns Hopkins and observed how doctors work and asked a lot of questions over many weeks. The result was a system called Team Notes that physicians there and now in multiple other hospitals find very functional. [Full disclosure - I am on the board of directors] We need more attempts like this to overcome the issues and problems raised by Dr Shah.

[John A. Liebert, MD]

Stephen Shimpff makes an excellent observation and contributes the name of commercial innovators with a possible solution; Salar's website is, indeed, promising. And, if they are experienced practitioners who direct softwared development, then their products could be promising. Note, in my comment regarding collegiality in development of enterprise software that I emphasize the need for all constituencies to be at the table - not just the DNR, Medical Director and CIO. They rarely, in these days, really represent the needs of staff but are mainly mediators or representatives of governance, rather than clinical staffs, whether pharmacy, medical, imaging, nursing, security etc. The former are 9-5, while patient care is 24-7. Salar does have "team notes", for example, suggesting awareness and attention to this demand in truly lean managed patient Throughtput.

My question is, if the big vendors, as you say, "know the problem exixts", then why don't they invest their considerable free cash flow, as well as a portion of what they certainly have already budgeted from guaranteed funding out of the Stimulus Package, to find out what constituences within clinics and hospitals really need? I think I know the answer to this, but I would be interested in other insights, in hopes that I am wrong.

And, now we have Google and Microsoft getting into this too! What has been their frontline experience so far - i.e. Eastside Seattle or Silicon Valley hospitals serving their own medical/surgical needs? John Liebert, MD

[lawrence a saltzman]

All well said, and very related to something posted at the blog, US-Canada Health Technologies--
http://USCANADAHEALTHTECH.blogspot.com about the myths of healthcare technology

[John A. Liebert, MD]

Thank you for posting this informative text. A couple of things stand out here that could be very misleading. First of all, AHLTA is not a US MIlitary EHR; it is a US Army EHR, considered to be in great need of either renovation or scrapping in entirity from the very top of Army Medical Command - i.e. retention of medical corps personnel is considered to be adversely affected by the burdens of its use.

And, the divergence of the Canadian Healthcare System and ours in the US prevents sweeping comparisons so often made because, for the most part, we have common language. For example, ERs in Detroit and Windsor have very different epidemiological demands because of prevalence of random shootings south of the honker line. Guns are illegal in Canada, but ubiquitous in Michigan - and everywhere else in the US also. This discussion is not about Gun Control, but it is a caveat re simplistic and reductionistic testimonials to transfer of centralized processes from one entity to another - i.e. US Army to US Citizens, before trying them out on the US Navy in between - or imposing Canadian Emergency Healthcare services on to the US before buying a helicopter for Level One Trauma Care in Quebec. Too often such text, like yours posted, is read without realizing that critical citations - i.e. "ALHTA is a Military EHR" and centralized Canadian healthcare achievements - are oftentimes official testimonials to justify expenditures of billions or internal testimonials to prevent transparency into how processes develop politically, whether from Provinical Capitols or Ottawa. In Canada, everything flows from the top down, because health care, with minor new exceptions, is essentially our Medicaid - not Medicare - system, and supposedly, bypassing Provinical insurance for reimbursement is illegal. Again, Quebec is an exception, in that their Supreme Court declared "One Payer" unconsitutiona in a patient's appeal for right to pay for treatment and avoid either waiting or going to US hospital! John Liebert, MD

[Bari Shein]

Dr. Liebert,

Your insights, which I believe are correct, present an obstacle for me relative to my current job search. One of my areas of focus are EHR vendors. Thus, as a person in this position I would appreciate comments, as to which vendors to apply to, contacts people may have within those companies, and any other information that can provide useful advice/council to one in my situation. While I'm at it, the other area of interest to me is that of HIE's - again I have heard much of the good, bad and the ugly. However, I will be attaching a post relative to the state of HIE's, just published by the e-health Initiative. Again everyone has an opinon but would appreciate feedback/council and advice on this area/article, as well. I thank anyone, in advance, willing to assist.

Bari Shein