Readers know of my criticisms of the electronic medical record (EMR) juggernaut that is oozing over the medical landscape. Ultimately, this technology will make medical care better and easier to practice. All systems will be integrated, so that a physician will have instant access to his patients’ medical data from other physicians’ offices, emergency rooms and hospitals. In addition, data input in the physician’s office will use reliable voice activated technology, so that some antiquated physician behaviors, such as eye contact, can still occur. Clearly, EMR is in transition. I place it on the 40 yard line, a long way from a touch down or field goal position.

A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I’m not a businessman, but I have learned that when something owns you, it’s generally better for the owner than the ownee. This meeting was about the hospital’s upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made. In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients’ care. It would solve the perennial problem of inscrutable physician handwriting, including mine.

One advantage that computerized ordering aficionados claim is that physicians’ orders can now be standardized for various medical conditions, such as stroke, congestive heart failure and diabetes. Of course, patients are unique and may not neatly fit into packaged computerized ordering templates. Will deviating from these standard order sheets by easy, or will we need a 14-year old beside us to help us over the cyber hurdles? Most of us have been issuing medical orders on paper for decades, without loss of life or limb. When I write an order with a pen for a potassium supplement, for example, I have not found the task to be onerous. Will the computerized system be another example of solving problems that I didn’t know that I had?

One of the physicians at the hospital meeting asked if the verbal order policy would remain. The response suggested that verbal orders would no longer be permitted. The physicians wondered how they would give admitting or other orders at 2 a.m. Would they have to boot up a computer at that time? What if a nurse calls for an urgent blood transfusion order when the physician is in his car? Does this enlightened verbal order ‘reform’ sound like it originated from folks who understand doctors?

I have to hope that the speaker was misinformed, as this aspect of the policy is simply too dumb to survive, at least I hope so.

I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don’t practice medicine or understand physicians’ needs. What’s good for billers and coders may not help physicians in exam rooms with living, breathing patients.

I am sure that most physicians who are retiring now do not regret that they will miss the steep vertical climb from paper to electronic medical practice. Personally, I am glad to be part of it, although I wish that ‘point & click’ medicine was more about medicine than about pointing and clicking.

Perhaps, this approach can be extended to blogging. Right now, it takes me a while to pound out these posts. If I could use a packaged medical ranting blogging template instead, then I could post a Whistleblower twice daily. Point & click blogging. Hmm. I can see the goal line.Become a subscriber!

Michael Kirsch, MD, is a private practice gastroenterologist in the Cleveland, OH, area. He shares his thoughts about issues in medicine and medical practice at MD Whistleblower.

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22 Responses for “Electronic Medical Records Attack Hospitals”

  1. S. Suresh says:

    The first two paragraphs of your write-up are fact-based. Appreciate that. The rest are not.
    1. Standardized order sets for Congestive Heart Failure – These ensure that the basics (Diuretics/Digoxin/Diet/Oxygen, etc) are covered, and you always have the option of adding more orders or deleting what is already part of the template. You might have not find the task of ordering supplemental potassium to be onerous, but how do you know that the dose is right every single time? How about the potassium orders hand-written by less experienced physicians than yourself? Please do not assume that every single order that you wrote on paper over the years was correct. You cannot prove it, and neither can I prove that you have made mistakes. Chances are though, that you have- just like any physician who practiced with paper and a phone.
    2. Most hospitals have the common sense to expedite an urgent blood transfusion (and also code meds, and life saving measures), without waiting for an electronic order. If this hospital in your write-up is not doing it that way, that is short-sightedness on their part; EMR is not to be blamed.
    3. Can you honestly admit that you have covered every relevant question in every history that you have taken? Neither does an EMR, but certainly improves the success rate (compared to the average physician’s brain).
    3. Please do not give readers the impression that physicians ‘in exam rooms with living, breathing patients’ without an EMR do a better job that physicians who use EMR.
    Very few physicians will admit that (a) perceived loss of control and (b) insult to their ‘doctor ego’ with the increased usage of EMR, is in fact the reason that they do not buy into EMRs.
    EMRs are clearly not perfect- and probably never will be. EMRs have killed and maimed fewer patients (in the post-EMR world) than what physicians have done (in the pre-EMR world).
    Just like you, I am a practicing clinician with nearly 20 years experience. I have not had a single instance where I had to compromise the way I have to talk to and manage a patient- just because I was asked to use an EMR (for the past 10 years).

  2. Plan your eMR Escape Hatch
    Good post Dr. Kirsch. Of course, you will spend weeks or months in the “sales and demo cycle” for selecting an EMR. If you’re lucky you will have time to consider all workflows; if you’re even luckier you will test drive the UI and make sure training goes smoothly. You will also try to ensure that deployment will be easy. However, another thing not to forget is to plan how to get out of an application or system after it’s been installed for a while.
    Why is getting out important? Every application looks better in a demo than in a working environment and every solution becomes “legacy” sooner or later. Every system will be replaced or augmented at some point in time. The cost of acquisition (“barrier to entry”) is well understood now as something we need to calculate. But the “barrier to exit” or switching cost is something you must calculate at the time you decide what systems to purchase.
    If you can’t answer the “how, in 6, 18, or 24 months, will I be able to move on to the next-better technology or system?” question then you’ve not completed your due diligence in the sales cycle. Vendor sales staff are quite reticent to answer the “how do I leave your system” question; you will need to press hard and ask for a plan before signing any contracts.
    When preparing an RFI or RFP, ask vendors specific questions about how easy it is to get out of their technology (rather than just how easy to it is to deploy and interoperate). Put in specific test cases and have your folks consider this fact when they are looking at all new purchases.
    And, according to Shahid N. Shah MS, writing for chapter 13 in the third edition of our book, the “Business of Medical Practice”, here are some specific “escape” factors to consider:
    • Do you own your data or does the vendor? If you don’t have crystal clear statements in writing that the data is yours and that you can do whatever you want with it, don’t sign the contract. Look for a new vendor.
    • Is the database structure and all data easily accessible to you without involving the vendor? If only your vendor can see the data, you’re locked in so be very wary. Find out what database the vendor is using and make sure you can get to the database directly without needing their permission.
    • Are the data formats that the system uses to communicate with other vendors open? If not, you don’t own your data. Be sure that at least CCR and CCD formats are available and that all document data is accessible in standard PDF or MS Office friendly formats. Discrete data should be extractable in XML or HL7.
    • How much of the technology stack is based on industry standards? The more proprietary the tech, the more you’re locked in.
    • Are all the programming APIs open, documented, and available without paying royalties or license costs? If not, when you try to get out you’ll pay dearly.
    Good luck!
    Dr. David Edward Marcinko MBA
    http://www.BusinessofMedicalPractice.com
    [Editor-in-Chief]

  3. Gary Levin says:

    You must have been facetious when you said, “antiquated eye contact”???

  4. propensity says:

    Thanks for stepping up. However, I disagree with one point. CPOE is on the on the one yard line, on the verge of a safety. EHRs as libraries of data are on the Forty yard line, perhaps.
    The vendors have covered up the defects in the CPOE products they sell. The gamut of injuries, deaths and hazards is unknown. Just recently, 2000 charts of orders vanished for 4 (according to the vendor) hours in Seattle.
    These are medical devices that are being sold without FDA approval for usability, safety, and efficacy. There is not any after market surveillance.
    Hospital administrators are not desirous of hearing of the adverse events associated with these devices, nor are the vendors. No matter how unusable the devices are, both partners, if told of an adverse event in this experiment, invariably blame the users, deemed “learned intermediaries” in the contracts.
    The benefit for patients from the fact that the vendors have not submitted their devices for the FDA for approval is that the vendors can be sued by the injured parties.
    If the devices were approved by the FDA and the vendor followed the correct procedures, the Supreme Court has given them immunity from lawsuits if a patient suffered injury due to the device.

  5. DeterminedMD says:

    I am going to write something that will inflame, but it has to be said, because the dumbing down of medicine by outside influences is one thing, but when it is enhanced by our inner circle of colleagues, who are just brainwashed by this quick fix mindset that the computer technology has sold, it is also shameful at the expense of learning a craft called meidicine.
    Electronic records have strengths AND weaknesses, and to hear people dismiss any idea of weaknesses or complications is very unnerving. Waiting to find out from painful incidents and repeated circumstances is NOT the way to fix or undo problems. Medicine is gray, the computer is black/white, 0/1. You can have a basic template, but if it gets “too involved or too time consuming” to write in exceptions or alterations for each individual patient, people will suffer!
    And, this is the painful/inflammatory comment: now that residency is a 16 hour day at most, it only presses further for quick fixes and solutions. Our younger colleagues and colleagues-to-be are in the process of selling out the profession once and for all. When colleagues are on the receiving end of this cookie cutter approach to care either as patients or invested family members/sig others to patients, then the truth and reality of this failed premise will impact. But, will it be too late to make changes for the better? Hospitals are monoliths, and moving them are what amounts to an act of God.
    Careful what you wish for, eh?

  6. John Sharp says:

    I agree that EMRs have strengths and weaknesses. In the case above, I hope that there is a physician advisory group for the EMR implementation to address questions which impact practice so that modifications to the EMR can be voiced. Like any good software, it is essential that the software fits the workflow, and not require the users to completely change their workflow to accommodate the software workflow.
    I disagree with the concept of the dumbing down of medicine. Medicine has become so complex with rapid growth of knowledge that electronic systems are now essential to practice.

  7. BobbyG says:

    @ John Sharp | Jan 30, 2011 5:09:26 PM-
    Indeed.

  8. dean r says:

    As a stroke survivor I really look forward to something like this, we might actually get to the point where a damage diagnosis is given for both the penumbra and the dead brain area. Then researchers could finally correlate therapies to damage and recovery and survivors would not be left in complete limbo as to what to do to recover.

  9. Judy Osterman says:

    Dear Dean,
    “Then researchers could finally correlate therapies to damage and recovery and survivors would not be left in complete limbo as to what to do to recover.”
    Are you kidding me? I suggest that you find a competent neurologist, physiatrist, and physical therapist. EHRs currentl result in deaths and injuries and strokes. Your dreams are light years away.

  10. Dear Judy,
    Dean is not kidding you.. and although “EHRs” may be “light years” away from this reality, appropriately designed computer systems are not. I have published on this fact here: Computerized clinical decision support: a technology to implement and validate evidence based guidelines. My group has created Computerized Clinical Decision Support(CCDS)systems that have augmented the clinical care of hundreds of patients, leading to improved practices, as well as changes in practice. This will ultimately be the way of the future. Unfortunately, we continue to be bound by a myriad of problems related to poor design, poor understanding, poor planning, and a legacy of thought processes that need to be challenged.
    BTW. Lot’s of great comments. I wanted to say most everything that has already been written here.

  11. Craig "Quack" Vickstrom, M.D. says:

    My question was, and remains: why are we implementing EMRs when they are still in the beta phase? Not one of them is truly ready for deployment. Why are they being stuffed down our throats before they are truly safe and effective?

  12. pcp says:

    ’3. Please do not give readers the impression that physicians ‘in exam rooms with living, breathing patients’ without an EMR do a better job that physicians who use EMR.’
    It’s not an impression. The evidence shows no difference in performance, whether or not an EMR is used.
    ‘although “EHRs” may be “light years” away from this reality, appropriately designed computer systems are not.’
    The problem is that, after being processed through EMRs that are just glorified billing machines, the data is so corrupted as to be useless (and maybe even dangerous).

  13. “verbal orders”!?
    Accrediating, regulatory, safety, and quality agencies have been dinging hospitals for them for years! In case the hospital has no hospitalists I would be happy to turn on my computer at home at 2 AM to enter orders for a patient admitted by an emergency room physician. In my hospital no GI physician comes in at night unless he/she can do a reimbursable procedure. This post not only sounds like sour grapes. It is “old” grapes.

  14. Great comments all. Agree with Craig who points out the obvious; why roll this stuff out half-baked? Would we approve a drug or certify a physician as qualified if they were only ‘on the forty yard line’? I doubt it. We’d release them when they’re ready.

  15. Cheryl says:

    Waiting until the EHR is ready before rolling out?!?! While you’re at it, I suggest you hold off on buying that next computer, phone, car, whatever, until ALL the bugs have been worked out? Are you sure all the kinks have been worked out of a newly minted surgeon or are we taking a risk that the training was adequate and sufficient?
    CMS thinks the techonolgy is ready, and through the HITECH Act, mandates that hospitals use “certified” technology. So…whose certifying that technology if it’s still half-baked?

  16. “I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don‚Äôt practice medicine or understand physicians‚Äô needs.”
    I agree. Our journal has published a few research articles that show EMR systems (in their current iteration) are not the saviors of the healthcare system that bureaucrats would like us to believe.
    Computerized records (in their current form) don’t save money.
    http://www.amjmed.com/article/S0002-9343(09)00816-X/abstract
    Copy and paste functions can lead to errors.
    http://www.amjmed.com/article/S0002-9343(09)01104-8/fulltext
    Good article.
    Pamela J. Powers, MPH
    AJM Managing Editor

  17. Nabeel says:

    As you can see their is a lot of different reactions from this post. I would like to share this with everybody:

    The Office of the National Coordinator for Health Information Technology (ONC) released statistics which showed that 81% of the nation’s hospitals and 41% of office-based physicians intend to register for federal incentive payments for adoption & meaningful use of certified Electronic Health Record (EHR) technology.David Blumenthal, national coordinator for health IT, in keeping true to staying abreast of technology posted a YouTube speech in which he laid out the work that was being done by the ONC & the promising statistics for Health IT Implementation.

    Learn more on http://www.NortecEHR.com on $44,000 Government Incentives avail.

  18. Howard Crawford says:

    My background is in corporate IT management and project management. Perhaps this gives me a different view point from many others who have posted comments here. Still I hope some of you will find my comments at least worthy of consideration.

    The amount of misunderstanding of the process of rolling out any new IT service is truly perplexing to me. I understand that most of the people here are medical professionals and delivering medical care to patients is there focus, but haven’t some you been involved in projects where the process of acquiring inputs from various stakeholders is needed in order to meet business requirements?

    I would like to focus on the comments the American Journal of Medicine makes. I don’t mean this as a personal attack but I think their point of view is a common one so I hope I can bring a different perspective to the issues discussed above that I hope will help to start a more productive dialog in the future.

    “I also believe that many of these systems were designed by folks who don’t practice medicine or understand physicians‚ needs.”
    Of course you are correct. Such systems are designed by software and hardware engineers. Yes, and we don’t want these people operating on patients either. But this is nothing new. Who designed the blood pressure machines, CT scanners or any of the technologies that are used on a daily basis in any hospital? Engineers. Do they know much if anything about patient care or the illnesses that the machine may diagnose? No. It is at the point that the technology interfaces with the user, being the nurse or physician that is where a team approach is needed and input is solicited from the end-user to meet the user’s requirements. If this is not done properly, it is not the fault of the technology but the fault of the user interface designer to do their job properly. Unfortunately the human factor is also problematic in such complex design issues. Do you know how your car works? Do you need to no? No. A person does not need to understand the full working of a device to use it as a device/tool to get particular results. Do you know how your computer works or the Internet? No but we are using it as a tool to communicate with.

    As someone else said, we all might as well throw out all the electronic devices we have because there are always better systems to come in the future as IT and systems knowledge advance. Who is using DOS or driving a Model T any longer.

    That EMR systems are the saviors of the healthcare system, “the silver bullet” is as ludicrous as any one thing being “the answer” to anything. The history of medicine has shown this over and over. It is a mute point. Things evolve through time. We don’t come to an end point of perfection in life, art, medicine or technology. Everything is constantly changing, evolving.

    As far as your comments on cutting and pasting…It is not the technology itself that creates the problem mentioned, it is the human factors. To blame electronic systems for the ability to cut and paste is like the student who cuts and pastes large parts of their school paper then says it wasn’t his fault it was easier copying something from somebody else then saying it in his own words. This is a case of whether technology is used for good or ill. It is not the technology itself that is inherently evil.

    To take data from hospitals during the period from 2003 to 2007 when data is siloed in different databases using incompatible standards to integrate the data and to pretend this is EHR is comparing apples and oranges. They are not equivalent and can not be used to compare one to another.

    I have the utmost respect and admiration for medical professionals and am dismayed but the lack of understanding of the basics of the use of technology as an adjunct in delivering high quality healthcare at a reasonable cost. Obviously there is a distrust issue between many areas of healthcare and the IT departments who are responsible for understanding the business they are in and how together we can collaborate to service our patient communities. Based on my own experience, I believe it is IT’s responsibly to come out of their kingdoms create a dialog with all their business project stakeholders. This division is having a negative impact on our healthcare systems and on the quality of healthcare in this country. I hope that IT will join with our heathcare colleagues and begin a new relationship based on mutual interests that will benefit all involved.

    Sincerely,
    Howard Crawford
    Pharma IT Consultant

  19. Doc B says:

    EMR’s with templates that import labs, vitals and previous days’ progress notes also lead to errors and potential fraud.

  20. charlaspence says:

    While electronic medical records will likely be a solution in the future the reality, from a patients perspective, is that they have a long way to go. In the meantime, life and medical issues do not stand still and wait for this development to take place. So, there needs to be a bridge system to accomodate current needs. I suggest that a Personal Healhcare Record maintained by the individual patient if the best way to do that. The patient becomes a the most complete source of truth and the most important member of the healthcare team. By taking charge and accountablity for their own healthcare (or those they care for), they avoid the pitfalls of the current electronic systems – system compatability, security of information and system failure e.g. natural disasters taking out systems. Sometimes the best technology is no technology.

  21. saç kaynak says:

    it’s really interestly…

  22. alex d says:

    Occupational health professionals must manage the complexities of medical surveillance. They have to record employee health data from workplace injuries and illnesses, clinic visits, immunizations, audiometric exams, flu clinics, wellness programs, and lab tests. And, it’s not enough to just collect the data: They must be able to report on it in multiple formats.

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