We’re hearing a lot about the use of electronic medical records (EMR) in medicine. The government is all for it—providing financial incentives for those with EMRs and disincentives for those still relying on paper charts to make their way through the world. Most health professionals, especially new physicians in training, simply can’t imagine a world without an EMR at their fingertips.

The ability to electronically capture discrete bits of data on each patient allows us to categorize, tally, and build unbelievably beautiful charts and graphs.

These systems also uncover deficiencies in patient care; with the push of a button, we know whose blood pressure or blood sugar is out of control, or how many patients weigh too much for their height. Clinicians click-through as many templates as possible in order for the system to capture these professional nuggets of information. Nuggets worth their weight in gold to researchers and pharmaceutical companies, eager to market their next blockbuster drug to physicians whose patients just happen to fit their marketing profile.

The trouble is when you’ve seen one template–built patient medical record, you’ve seen them all. These systems do such a great job of capturing discrete bits of data that patients become just that—only discrete bits of data.The essence of who they are, their story, becomes lost in attempts at efficiency.

What interests me about each patient is their story: what’s happening in their life that brings them stress or joy. Are they wanting medication for their cough, or really just needing assurance they don’t have lung cancer. Each visit brings a new chapter, a peeling of the onion allowing me to see the various layers of their personality over time. This is more important than almost any other discrete piece of data we could fit into a template. It takes time and effort to build an electronic medical record that speaks for the patient; time that is often in short supply for busy clinicians.

Oscar Wilde once wrote, “The cynic knows the price of everything and the value of nothing.” We certainly know the price of a robust EMR, but its value for helping us know each patient is unclear. Before we jump on this wagon of bandwidth, we need to understand what we hope to gain and the value it brings to the person that counts—the patient.

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38 Responses for “The Neverending Story”

  1. SteveBMD says:

    It never ceases to amaze me that I can get more information about a patient in a 60-second phone conversation with another doc, than from 60 pages (or more) of EMR-generated chart notes.

    Granted, I’m a psychiatrist, where the “story” is what’s important, but I think what you say is true for all of medicine.

    There is no value in an EMR to me, or to my patients. Just to the owners, purveyors, and purchasers of the information contained therein.

    • BobbyG says:

      A lot of physicians would disagree with you. It’s easy to diss people like me as a mere “purveyor,” (I work in Adoption Support for an REC), but that ad hominem won’t work when aimed at other doctors who find significant net utility in HIT.

      Moreover, you, and Steve Sanders, assume that the point & click, radio button/pick-list templated architecture is the static end game. While a lot of that is driven by the coding/billing imperative, it’s not all there is. It’s now a trivial thing to record a pt or referring doc interview into mp3 format and attach the file. Similarly, I was was at a MacPractice EHR demo here other night where the presenter dropped a video file right into the chart. he also flawlessly built a section of “subjective” narrative (in the SOAP) using MacSpeech Dragon. I already knew that would work, as I use the same product here at home on my iMac; it’s 4 times as fast as typing, and makes fewer mistakes.

      “These systems do such a great job of capturing discrete bits of data that patients become just that—only discrete bits of data.The essence of who they are, their story, becomes lost in attempts at efficiency.”

      That is simply NOT true. My own Primary has been on an EHR since 2004. Our doc-pt relationship is enhanced by the efficiencies his system provides.

      “when you’ve seen one template–built patient medical record, you’ve seen them all.”

      Actually, once you’ve seen one, you’ve seen ONE.

      One of the difficulties we face is that there are as of today 363 ONC certified ambulatory systems alone (254 of them “complete EHRs”), none of which had to demonstrate any design/usability criteria for this Meaningful Use initiative — and, I have been loudly critical of that.

      “What interests me about each patient is their story: what’s happening in their life that brings them stress or joy. Are they wanting medication for their cough, or really just needing assurance they don’t have lung cancer. Each visit brings a new chapter, a peeling of the onion allowing me to see the various layers of their personality over time. ”

      I could not agree more. That the billing/reimbursement imperative obstructs these ends is not the fault of information technology per se.

  2. pheski says:

    Great column, Steve,

    As a family physician, I too find the ‘story’ to be far greater and more useful than just its parts. While the eHR certainly collects and displays far more data points, more is bigger but not necessarily better. Most importantly, more is definitely different.

    A group of 30 is not just bigger than a group of 3. It is an entirely different entity. Getting effective communication, cooperation or collective action from a group of 3 is possible, but try to get 30 people to agree on what movie to see!

    Extracting sense from data is never trivial. The larger the data pile, the greater the challenge. The eHR treats data as discrete pieces of information and, unless it is coupled with complex and powerful logic – as well as a soul – it is a repository. As in a hole in the ground into which one tosses stuff.

    We are at the very beginning of what will be the tough process of developing an eHR that is usable for useful and meaningful patient centered clinical activity. I hope I live to see that day. While I would’t go so far as to claim that there is no value to me or to my patients in my eHR, for me it’s just a primitive tool. Emphasis on primitive.

    Peter Elias, MD

  3. BobbyG says:

    “Before we jump on this wagon of bandwidth, we need to understand what we hope to gain and the value it brings to the person that counts—the patient.”
    ___

    I could not agree more.

    Given that the increasingly widespread adoption of HIT is pretty much a done deal, it behooves everyone involved to make sure it serves in the patients’ interests as the primary consideration.

  4. Brenda S says:

    As a family nurse practitioner who uses e- records I can tell you that they make patient records legible, organized, and easily available. Each practitioner has the option to make the templates more subjective and appropriate for the patient. I try to do it, one as a way to connect and remember the patient and the other is to individualize the record. Each person is unique and deserves to be recognized so. But overall I feel the e-record is the wave of the future. Enough with trying to read practitioner’s illegible handwriting and waiting for consult letters.

  5. Sharon, RN says:

    You hit (not HIT) the nail on the head. To my physicians, the EHR is an impediment to good care, creating the omnipresent need for workarounds in order to provide safe care despite the EHR.

    I find it ludicrous that programmers like Bobby G above, aka industry shills, who know nothing about the intricacies and nuances of medical care create devices that endanger patients daily.

    MedInformaticsMD writes on this at Health Care Renewal, a must read blog for those who like what Steve wrote. keep writing, Steve.

    Sharon

    • BobbyG says:

      Sharon, Read my REC blog. I am not a “programmer” nor an “industry shill.” I am a statistician by training and long experience. And, I am quite critical of HIT where warranted. Spare me.

      “who know nothing about the intricacies and nuances of medical care”

      That is complete crap. Read my blog. All of it. I WORK with doctors and nurses EVERY day. Spare me. And, again, you can diss me, but you cannot so easily dismiss the many, many actual physicians who would disagree with you (including all four of my Medical Directors).

  6. SteveBMD says:

    I’ll have to side with Sharon on this one. And Bobby, I find your contemptuous reaction quite unflattering.

    I’m all for technology, and Bobby, the implementations you described in your first post (mp3′s, videos, etc) sound great. The problem is, as Sharon pointed out, the changes are NOT being driven by patient-centered (or even doctor-centered) motives, but by people who just see the business opportunities. Most of the HIT guys I’ve worked with DO in fact “know nothing about the intricacies and nuances of medical care.” It’s sad, but true. I hope you’re the exception. If so, the field needs more people like you.

    • BobbyG says:

      Read my REC blog.

      When someone — contemptuously, btw — mischaracterizes my experience or my motives, I will cut right to the chase in pushback.

      “I find it ludicrous that programmers like Bobby G above, aka industry shills, who know nothing about the intricacies and nuances of medical care create devices that endanger patients daily.”

      If that is not “contemptuous” (in addition to its inaccuracy), the word has no meaning.

      The off-topic, hyperbolic incivility on this blog far precedes my coming here. I would be perfectly fine were it moderated. I’d still be here. A number of others would not. In particular those who use untraceable screen names to take potshots at others.
      ___

      ” the changes are NOT being driven by patient-centered (or even doctor-centered) motives, but by people who just see the business opportunities.”
      ___

      Again, I agree with that to a great extent. And, I object to it consistently.

    • Nice blog, indeed. I have a blog also and have been witing about EMR, HIT,ONCHIT RHIOs and HIEs since 2004. I am placing your blog link on my site. @glevin1

  7. Alan Touring says:

    Why are you blaming the EHR for E/M coding and a payment system that requires voluminous but irrelevant documentation? Is EHR just an easier target? BobbyG is spot on – the tool can be wonderful, but it has to meet all the stupid business rules that have absolutely nothing to do with patient care. If we didn’t have to count bullets and think of every progress note as court document that you would see such crappy notes? You don’t like having 24 hour access from any site, trended data and patient entered information? EHR needs to evolve. It has to be built by the IT people that you love to hate because physicians can’t/won’t build it.

    • BobbyG says:

      Thanks.

      Again, so much mischaracterization, so little time. e.g.,
      ___

      “the changes are NOT being driven by patient-centered (or even doctor-centered) motives, but by people who just see the business opportunities.”
      ___

      Well, while it ought be a Blinding Glimpse of the Obvious that business people will jump on opportunities (particularly when they’re federally subsidized), I have to take issue with that broad-brush characterization. Read “The Federal Health IT Strategic Plan: 2011-2015″ just released:

      http://www.cmio.net/index.php?option=com_articles&view=article&id=26954&division=cmio

      Read also the antecedent PCAST report. HHS et al are pushing hard for “patient-centered” reforms (with Republicans vowing to throw sand in the gears at every step). I might add that, last time I checked, there were no senior federal officials pulling down 7 to 8 figure compensation packages.

      Regarding the evolved reimbursement paradigm, I regard with total disdain the drive-by documentation hoops a doc must traverse in a limited amount of time just to defensibly code a crappy “moderately complex” 99214 (e.g., whiz past the FH, SH, PMH, CC, HPI, vitals, labs, and — what? — at least 5 of the 15 ROS categories, scurrying past perhaps a couple hundred variables while building a billable, audit-proof SOAP note).

      Dunno, man. I’m on the side of docs here. That seems to repeatedly get lost.

      For me, personally, were it just about “business opportunity” I’d simply go back into credit risk modeling (again, I’m an analyst, not a programmer). I could make 3 times the money, given that the major scoring models are now way “out of calibration” owing to the burst bubble.

  8. Alan Touring says:

    Cross posted from HISTalk: http://histalk2.com/2011/03/26/monday-morning-update-32811/

    From GI Doc: “Re: NEJM article. What do you think of it? It’s certainly a laundry list of problems in healthcare IT, but all I can see are a lot of vague prescriptions based on wishful thinking about how to solve them. But it sure puts the author in a position to say ‘I told you so’ about just about anything that can and probably will go wrong in the future.” It’s hard to believe this compendium of trite EHR observations warranted NEJM real estate. How many times do we need to read that healthcare IT has potential, but more work is needed to make it perfect? I’m as cynical as anybody, but those who use lack of perfection as rationale for doing nothing annoy me. I can’t think of any other industry that has argued so hard against using computers, although I’d support more government standards and even internal, IRB-type oversight within a given institution since I’ve worked in enough well-intentioned IT shops to distrust their project objectivity vs. patient safety (and some hospitals stupidly let their IT department single-handedly run projects that directly affect patients, which makes as much sense as turning them over to the departments that oversee electrical and plumbing). I’ve concluded that almost no one is objective about healthcare IT: the same person is nearly always for it or against it and will argue their position endlessly. Someday they’ll figure out that IT is neither good nor bad, so it deserves neither universal accolades or criticism — it’s just a tool that can make outcomes and cost better or worse depending on who’s using it, what they’re using, and how they’re using it (no different than a paper chart, an antibiotic, or a scalpel). Technology alone rarely makes sucky providers better or excellent providers worse.

    I’m running the first of my “time capsule” editorials I wrote for an industry newsletter over several years (odds are you haven’t seen them since it was a boutique-type publication with a limited, high-level audience and no free subscriptions). I didn’t want to send an e-mail blast because some high-strung reader was sure to complain about the two seconds required to delete it, but the first is Is Forcing Physicians to Use Computers a Flawed Paradigm? I wrote it in 2006, but I’ll be surprised if it doesn’t still trigger some impassioned comments.

  9. Sara Stevens, CRNP says:

    *Technology alone rarely makes sucky providers better or excellent providers worse.*

    I see the mistakes that some of the most respected and clinically gifted doctors have made associated with flawed CPOE and its interfaces. Communication fails, orders do not get to the intended recipient, and the doctors’ brains are obverloaded with pages of gibvberish causing them to cognitively dysfunction. This is a known fact and HIStalk is falt out wrong in his statement.

    • BobbyG says:

      But these bad things NEVER happen on paper systems, right?

    • SteveBMD says:

      Agreed, Sara. Technology can *indeed* make excellent providers worse. How so? It’s not because of something straightforward like wasted time, bugs/crashes, or lost data. It’s because, as pheski wrote above, what makes a clinician “excellent” is more than just his/her ability to collect, store, and use data.

      The clinical encounter involves the transfer of information on many levels– verbal, physical, emotional (dare I say even spiritual?). The best physicians are those whose interaction with patients involves all of these. Even the best EMRs force a physician to think differently about the encounter, and expect something discrete and quantifiable rather than the “gestalt” that characterizes any true patient encounter.

      Give it a few generations, and I’m sure MDs will catch up to the inefficiencies of EMRs; heck, I’m sure the same was said about the stethoscope and anesthesia when they were introduced.

      • BobbyG says:

        Dr. Steve, you need to add your input into the upcoming ONC effort to require “usability” as a certification requirement for EHRs. I would say that rapidly advancing technologies will in fact enable the physician to document the “gestalt” aspects of encounters in addition to the alphanumeric “structured data” that is now getting the bulk of the attention. “Usability” needs to incorporate such functionality.

        How do you document your work now? Are you saying you don’t have to document your findings in some reviewable medium? Even if they’re largely case narrative subjective (along with meds and other orders and referrals)?

        For better or worse, unless you simply practice “cash-only concierge care,” (which, IMO, will always be a vanishingly small niche catering to the affluent), HIT will be required by 3rd party payors, be they government entities or the various commercial insurors.

        • pcp says:

          “For better or worse, . . . HIT will be required by 3rd party payors, ”

          And why? Because 3rd party payors make big bucks when providers use EMRs.

          How about a little honesty here? Physicians are being forced to buy EMRs because it increases theprofits/decreases the losses of insurers and government agencies. It has nothing to do with better patient care.

          • BobbyG says:

            Not that there is not an element of truth in that (particularly on the “better patient care” side of things), but as a broad statement, that is simply too cynical.

            What’s YOUR solution? All I keep reading here are pretty much Perfectionism Fallacy” naysayings.

            I would disagree that it has “nothing to do with better patient care.”

            But, make your case.

          • pcp says:

            “Too cynical”

            No, just objectively looking at the evidence. That’s the opposite of cynicism.

            “Make your case”

            No, that’s not how it works. You’re arguing FOR something, so you should present the evidence that supports your case. Doesn’t it bother you that there is still no good evidence showing any benefit from EMRs, either in this country or from overseas, where they’re not shackled by our CPT system?

            “What’s YOUR solution?”

            Well, to begin with, I’m not sure what the problem is that people want to find a solution for. It seems to be quite broad and vague, something along the lines of “fix the screwed up American health care system.” If that’s the problem, then EMRs are just pretty Band-Aids on a gaping wound. If the problem is something more specific, like our high infant mortality rate or low vaccinations rate, I can think of lots better uses for the money and energy that is going into EMRs.

          • SteveBMD says:

            Re PCP (@ 7:15PM),

            “I’m not sure what the problem is that people want to find a solution for”

            You’ve hit the nail on the head. I’m in the 15th (!) month of an EMR “roll-out” in my clinic and each week there’s something new to learn, some glitch for which there’s a different workaround, or some different template to use. Now, I don’t mind changing the way I practice, but ONLY if my old way of practicing was wrong, broken, or unethical. And nobody has ever told me that it was (my handwriting was even legible, Brenda S!!).

            Sure, our system’s broken and needs fixing, and I’m all in favor of streamlining data collection, communication, and billing. But any effort to do this should NOT impose upon the one part of the health care system that people generally agreed was working (if not sacrosanct)– namely, the physician-patient interaction– and EMRs have done precisely that.

          • nate ogden says:

            “Physicians are being forced to buy EMRs because it increases theprofits/decreases the losses of insurers”

            I had no idea I was about to be rich. Besides an apparent complete lack of understanding on how insurance works where in the heck are you comming from? I would love to hear your logic on how you came to this conclusion. Please also specify if this is current law or post MLR cap that EMRs somehow make insurance comanies rich. You might have an argument for saving government money but there is no way you can connect the dot on EMRs and Insurer profit

          • pcp says:

            Maybe I should have said “richer.”

            There are many studies showing that the financial return on EMRs accrues primarily to insurers and government. One done by Massachusetts Blue Cross in 2008 showed 90% of it flowing in that direction. Not a bad return on someone else’s investment.

          • nate ogden says:

            I can create a study showing I am the most attractive man in healthcare, doesn’t mean its accurate.

            I still don’t see how it enriches the carrier. You would need to show the carriers’ profits increased by the amount of the EMR benefit. They have not, if the carrier’s cost decreased then their premiums to the employers would decrease. So its end payors that ultimatly save not insurers.

  10. Fannie says:

    To the shills who use the vapid argument cited above, no one is saying that paper is better, but there are sure begillions of time saving advantages and cognitively efficacious components to a complete paper record, all in one place.

    Just in terms of professional time saved, it is huge. Many think better when writing rather than clicking with thoughts at that time devoted to the clicker rather than the patient.

  11. Gary L says:

    BobbyG says:
    March 27, 2011 at 12:44 pm
    Dr. Steve, you need to add your input into the upcoming ONC effort to require “usability” as a certification requirement for EHRs. I would say that rapidly advancing technologies will in fact enable the physician to document the “gestalt” aspects of encounters in addition to the alphanumeric “structured data” that is now getting the bulk of the attention. “Usability” needs to incorporate such functionality.

    Actually this is ocurring now. The second phase of certification includes “usability”. However juding from ‘meaningful use criteria’ it will be useless as well.

  12. I’ve put together a reading list on the issues about health IT pros/cons.

    See it here: http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html

    Also see my teaching site on these issues at http://www.ischool.drexel.edu/faculty/ssilverstein/cases/ , started in 1999.

    S. Silverstein MD
    Drexel University
    Philadelphia, PA

  13. BobbyG says:

    “any effort to do this should NOT impose upon the one part of the health care system that people generally agreed was working (if not sacrosanct)– namely, the physician-patient interaction– and EMRs have done precisely that.”
    ___

    Again, a LOT of physicians would disagree with you, as a general dismissive statement. Any system costing roughly 2x per capita vis the rest of comparable industrial nations is not working all that well (for patients and doctors anyway), and can be significantly improved. Google, e.g., John Toussaint MD. Don’t take my Lowly Unwashed Word for it.

  14. pcp says:

    “Any system costing roughly 2x per capita vis the rest of comparable industrial nations is not working all that well”

    I don’t see anyone here defending that.

    What we’re looking for is evidence that EMRs can do anything to improve that ratio. In fact, many of us feel that in the US, EMRs serve to reinforce our dependence on the CPT system, a major source of our overspending.

    • BobbyG says:

      Interesting. Well, ANY improvement to an incumbent process tends to reinforce that process, I guess. Consequently, ____________________…

  15. Nice read, I just passed this onto a colleague who was doing a little research on that. And he actually bought me lunch because I found it for him smile Therefore let me rephrase that: Thank you for lunch! “Too much sanity may be madness. And maddest of all, to see life as it is and not as it should be” by Miguel de Cervantes.

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