Electronic Health Record: 16 minutes Per Patient

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What Went Wrong with EMRs: Death by a Thousand Clicks

Link: Death by a Thousand Clicks Where Electronic Health Records Went Wrong

This lengthy article highlights a lot of issues with EMRs/EHRs including data sharing between systems, pulldown menus, disruption of physician-patient interactions, upcoding, safety risks and provides numerous personal examples.

An excerpt:

The U.S. government claimed that turning American medical charts into electronic records would make health care better, safer, and cheaper. Ten years and $36 billion later, the system is an unholy mess…

Instead of reducing costs, many say, EHRs, which were originally optimized for billing rather than for patient care, have instead made it easier to engage in “upcoding” or bill inflation…

More gravely still, a months-long joint investigation by KHN and Fortune has found that instead of streamlining medicine, the government’s EHR initiative has created a host of largely unacknowledged patient safety risks…

Compounding the problem are entrenched secrecy policies that continue to keep software failures out of public view. EHR vendors often impose contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations…

EHRs promised to put all of a patient’s records in one place, but often that’s the problem. Critical or time-sensitive information routinely gets buried in an endless scroll of data, where in the rush of medical decision-making — and amid the maze of pulldown menus — it can be missed…

[Problem with scrolldown options]: [doctors] had to read the list carefully, so as not to click the wrong dosage or form — though many do that too..

The numbing repetition, the box-ticking and the endless searching on pulldown menus are all part of what Ratwani called the “cognitive burden” that’s wearing out today’s physicians and driving increasing numbers into early retirement…

Beyond complicating the physician-patient relationship, EHRs have in some ways made practicing medicine harder,.. “Physicians have to cognitively switch between focusing on the record and focusing on the patient,” … “Texting while you’re driving is not a good idea.a.. But in medicine … we’ve asked the physician to move from writing in pen to [entering a computer] record, and it’s a pretty complicated interface.

My take: This article makes many good points.  Though, if you polled physicians in our group, hardly any would choose to go back to what we had before EMRs.

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Reminders and Hard Stops -One Way to Improve Care Using an Electronic Medical Record

A recent study (MA Konerman et al. Hepatology 2017; 66: 1805-13) provides a tangible example of how an electronic medical record (EMR) could be helpful in improving care.

Implementation of EMRs has been a source of consternation for many physicians.  Some of the concerns include spending inordinate amounts of time completing documentation and how they can make the patient encounter less personal.

Nevertheless, with a good EMR, there is the potential for better care.  One way to implement a specific improvement is to place a “hard stop” or a reminder.  A hard stop can prevent completing documentation until an issue is addressed.  A reminder can pop up for appropriate patients to query whether a specific problem is being addressed.  In theory, both could be helpful; though, too many reminders can trigger alarm fatigue and too many hard stops can be quite annoying and further slow delivery of patient care.

In the above-mentioned study, the authors placed a reminder (“best practice advisory”) that encouraged screening for hepatitis C virus (HCV) among patients born between 1945-65 who lacked a prior HCV diagnosis and lacked prior testing.  This resulted in an increase in HCV screening in a primary care setting from 7.6% to 72% (one year after implementing).  Of the 53 newly diagnosed patients, all were referred for specialty care.  11 had advanced fibrosis or cirrhosis.

My take: Using EMR tools, specific screening goals can be achieved.  Before placing hard stops and/or reminders, we need to make sure that these goals are carefully selected to generate a net benefit.

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The Slow March of the Digital Health Revolution

A recent commentary (SD Dorn. Gastroenterol 2015; 149: 516-20) provides insight on the digital health revolution.

Key points:

  • “Amara’s law –that ‘we tend to overestimate the effect of a technology in the short run and underestimate the effect in the long run’–seems to apply to digital health. Expect short-term gains to be incremental.”
  • The promise of ‘big data’ has not translated into big changes yet.  “Many systems are not interoperable owing to cost, competition, privacy concerns, and technical barriers.”
  • Mobile health, mHeath, “is skewed toward those who need the least help: the young, the fit, and the educated.” And, there is “no evidence supporting the effectiveness of the vast majority of mHealth tools.”

What’s wrong with electronic health records?

  • “The overall evidence that EHRs improve safety and quality is spotty. Cost savings remain elusive.”  Some reasons include that more time is needed and/or flaws in EHR design.
  • EHRs are not very usable –excessive clicks and scrolling.
  • EHRs “reduce productivity and can add hours to the busy clinician’s day”
  • Physicians “now spend up to two-thirds of a typical outpatient visit documenting.”
  • Clinical records may be more legible, but they are often less useful.  “Template-generated notes frequently lack coherent narratives, are bloated with extraneous and repetitive information, and sometimes contain obvious errors that are copied forward from one note to another.”
  • “Physicians suffering from ‘alert fatigue’ may ignore potentially valuable clinical alerts.”
  • EHRs require frequent sign-ins and computers often have to be unlocked.
  • EHRs are expensive.
  • In total, EHRs significantly worsen physician satisfaction.

From a patient vantage, EHRs offer the possibility of patient portals to send physician messages, obtain test results, request medication refills, and schedule appointments.  Telehealth offers the potential for expert advice from great distances.

Some integrated health systems, including the Veteran’s Health Administration and Kaiser Permanente, have shown that EHRs can be successful.

My take: The transition to digital technologies has great promise but could lead to a less personal approach. So far, the transition to digital health has been a bumpy slow road.

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Atlanta Botanical Gardens

Atlanta Botanical Gardens

“Why Health Care Tech is Still So Bad” -NY Times

Here’s the link on this thoughtful article: “Why Health Care Tech is Still So Bad

This article highlights the problems including physicians distracted from patients due to data entry, problems with workflow, and alert fatigue. The author argues that we need to keep working on electronic health records; “the digitization of health care promises, eventually, to be transformative.”

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Copy Forward: What Could Go Wrong?

From GI & Hepatology News: “Copy and paste at your own risk”

Here’s an excerpt:

In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue…

When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her “accompanied by spouse” at every visit.

Quality care = Work Satisfaction for Physicians

From Atul Gawande’s twitter feed:

RAND study:

“Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy” Full article: http://bit.ly/19vVAnK 

1) Best predictor of MD work satisfaction: how we rate system’s care quality.  Physicians who felt that they were working in an environment with high quality care had higher work satisfaction.

2) Bad EHRs are killing us.  (Related blog entry: Aptly titled “The Cost of Technology” | gutsandgrowth)


Build the information medical highway and expect more traffic

A recent article indicates that increased patient access to online records was associated with increased in-person and telephone contacts (JAMA 2012; 308: 2012-19).

Background (from study introduction): The Institute of Medicine’s report on “Crossing the Quality Chasm” indicated that electronic patient-physician messaging was a promising technology to improve quality and efficiency.  Furthermore, previous studies have suggested that 25-70% of all visits to physicians do not require face-to-face appointments.

Design: To explore this topic further, the authors performed a retrospective cohort study on the use of health care services between 2005-2010 at Kaiser Permanente in Colorado.  This study examined patients ≥18 years old and looked at health care utilization before and after initiation of MyHealthManager (MHM). Users of MHM were compared with nonusers.  And, both groups (users and nonusers) were examined with regard to their health care utilization before and after MHM rollout. The first 30 days before and after activation of MHM were excluded from analysis to minimize the effect of increased utilization at the initiation of MHM.


  • By June 2009, patient use of MHM had increased to 53.8%.  In total, 87,206 MHM patients were identified and 71,663 nonusers were identified for study participation. 
  • MHM users were slightly older and more likely to be female.
  • After initiation of MHM, the rate of office visits increased by 0.7 per member per year (p<0.001) and the number of telephone encounters increased by 0.3 per member per year (p<0.001).  
  • The authors breakdown this data based on age, absence of chronic disease, presence of specific diseases (diabetes, coronary artery disease, congestive heart failure).  In all of these scenarios, MHM users had increased visits after initiation of MHM.  Nonusers generally had the same or less visits at the same time.
  • Figure 2 shows that MHM and nonusers had identical health care utilization beforehand.  Afterwards, the MHM users maintained a parallel line of increased usage that was fairly consistent for a year after rollout.

Why did this happen?  The authors note that the result was contrary to their expectations.  They speculate that individuals may have increased their in-person use after developing additional concerns following their review of information online and that individuals may sign up who are already more likely to use services.  Online access, in these individuals, may facilitate access to more frequent visits.

I think this article points to a more pervasive miscalculation of the effect of information technology and health care utilization.  While electronic health records (EHRs) can help organize and communicate vast amounts of information, the proposition that they will ultimately reduce health care costs/utilization or improve efficiency is looking dubious.  In my opinion, the best we can hope for is that EHRs, when used optimally, will improve the quality of the care.  It is equally possible, however, that EHRs could result in more legible but less accurate information due to well-recognized issues like copy-forwarding with inadequate editing.

Related blog posts:

Aptly titled “The Cost of Technology”

A brief commentary in JAMA makes some real useful observations regarding the effects of the electronic medical record on patient care (JAMA 2012; 2497-98).   The article describes a drawing by a 7-yer-old girl of her doctor who has an outstanding reputation among his peers.  Yet, in the drawing he is staring at the computer, and his back is to the patient.

The author notes that “when a physician focuses on a patient with complete attention, this simple act of caring creates a connection between two human beings. Almost immediately, the patient begins to feel, well, cared for, and this becomes a first step toward helping that person feel better.”

The computer is now a third player in this dynamic.  We “find ourselves entering more and more data while we are trying to listen to and talk with our patients.”  “By default, the patient moves down to second place…it is becoming the new reality.”

Physicians have to develop electronic records that allow us to record our thinking and improve efficiency so that we have more time to communicate with patients.  Can this be accomplished?

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Increased complexity or improper coding?

Not surprisingly, the adoption of electronic health records (EHR) has been associated with higher charges, especially in the emergency room setting (NEJM 2012; 367: 2465-67).  The question remains whether this increased complexity that is being billed is justified or simply due to “gaming” the system with electronic technology.

A specific example has been the increase in the highest level 5 codes used in emergency department (ED) visits, from 27% to 48% of Medicare charges (2001 to 2010).

While “gaming” may be part of the answer, more of the answer lies in the increasing complexity of patient conditions and more complex therapeutic options.  Specifically, the increase in higher coding has been associated with the following:

  • Marked increased use in new diagnostic technology. Overuse of technology is ill defined and failure to diagnose carries a much heavier penalty for physicians.
  • Increased numbers of patients without medical homes.  This increases the need for more diagnostic certainty.
  • Reduced hospital capacity.  Patients may be boarding in ED for quite some time before eventual admission or discharge.

Although the reasons stated explain how there may be more justification for higher complexity, it is well-recognized that EHRs facilitate billing by presenting check-boxes to more easily satisfy coding requirements.  This helps eliminate undercoding.  One of the drawbacks, though, with EHRs has been elaborate documentation at the expense of more direct patient contact.

Take home message:

The current system of coding is flawed.  While the complexity of care has increased, it remains difficult to identify the true value of the care provided. When most incentives reward increased testing and increased documentation which are easy to quantify, this is what will happen.