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.

Related blog posts:

Are Patients (but not Doctors) Better Off with EMRs?

A terrific piece by Atul Gawande explores the issues related to adoption of EMRs (electronic medical records): Why Doctors Hate Their Computers

He reviews in-depth many of the reasons why doctors face difficulties with their EMRs:

  • Spending twice as long in front of computer screen instead of with patients
  • Longer days
  • Endless problem lists
  • Inability to delegate some tasks (that previously were done by staff) and needing to provide more information on orders

“Gregg Meyer … the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade.

‘We think of this as a system for us and it’s not,’ he said. ‘It is for the patients.’

While some sixty thousand staff members use the system, almost ten times as many patients log into it to look up their lab results, remind themselves of the medications they are supposed to take, read the office notes that their doctor wrote in order to better understand what they’ve been told. Today, patients are the fastest-growing user group for electronic medical records.”

Hospital systems can use EMRs in various ways:

Other topics:

  • the emergence of scribes, including scribes in places like India where doctors transcribe recorded patient visits.
  • physician burnout
  • alarm/signal fatigue
  • ” the inevitability of conflict between our network connections and our human connections.”

My take: This is a terrific article and shows why physicians are struggling with EMRs; this article explains the problem in a way that is easy for non-physicians to grasp.  It shows that other professions face similar challenges.

Related blog posts on EMRs:

 

EMR Learning Curve -Long-term Benefits & Burnout Narrative

  1. Electronic Health Records Associated With Lower Hospital Mortality After Systems Have Time To Mature
  2. Beyond Burnout Moving narrative on the issue of burnout (JAMA link from 33mail -Bryan Vartabedian)

Related blog posts on EMRs:

Related blog posts on burnout:

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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South Kaibab Trail, Grand Canyon

 

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.

Related blog posts:

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.”

Related blog posts:

 

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.