Why Doctors Don’t Like Electronic Health Records

Why Doctors Don’t Like Electronic Health Records

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Why are doctors so slow in implementing electronic health records (EHRs)?

The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical. In 2004, the Bush administration issued an executive order calling for a universal “interoperable health information” infrastructure and electronic health records for all Americans within 10 years.

And yet, in 2011, only a fraction of doctors use electronic patient records.

In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs. The health IT industry has gathered at this multibillion-dollar trough, but it hasn’t had much more luck getting physicians to change their ways.

What is wrong with doctors that they cannot be persuaded to adopt these wondrous information systems? Everybody knows, after all, that the Internet and mobile apps, powered by Microsoft, Google, and Apple and spread by Facebook, Twitter, YouTube, and the iPhone and iPod, will improve care and cut costs by connecting everybody in real time and empowering health-care consumers.

I suspect the answer may lie partly in something essayist E. B. White said about humor. “Humor,” said White, “can be dissected as a frog can, but the thing dies in the process, and its innards are discouraging to any but the pure scientific mind.” Similarly, humanity withers when it is dissected and typed into an EHR. As Jerome Groopman, a Harvard internist, wrote in How Doctors Think, “Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment … but they quickly fall apart when doctors need to think outside their boxes, when symptoms are vague, or multiple and confusing, or when test results are inexact.”

The computer is oversold as a tool to improve health care, implement reform, cut costs, and empower patients. The reasons are obvious to anyone who treats patients. You cannot look a computer in the eye. You cannot read its body language. You cannot talk to an algorithm. You cannot sympathize or empathize with it.

We physicians are not Luddites or troglodytes. We are savvy about using the Internet, technology applications, and social media. For us, medicine mixes art and science. What we seek from patients are clues, constellations of signs and symptoms, and stories. We choose not to be reduced to data-entry clerks sorting through undigested computer bytes.

A string of numbers containing demographic, laboratory, and other patient information, no matter how systematically assembled or gathered, is not narrative. It does not tell a story. It contains “just the facts,” as Sergeant Joe Friday used to say.

That is why an ophthalmologist told me that when he gets an EHR summary, he ignores it: “It does not tell me the patient’s story. It does not tell me why the patient is here, what troubles the patient, and what the referring doctor wants me to do.”

There are also more mundane reasons why physicians, particularly in small practices, do not cater to EHRs or to their private enthusiasts and government backers. EHRs, you may hear physicians argue:

· are sold by so many companies—more than 100 at present—that no one knows how to separate the good from the bad and survivors from non-survivors.
· slow productivity.
· show negative investment returns.
· don’t speak to one another.
· distract from patient time.
· require total reorganization of practices.
· conceal a strategy for monitoring, controlling, and dictating practice activities.
· can be misused or hacked to invade privacy, reveal sensitive information, and threaten the security of patient and doctor alike.
· raise practice costs.

A word on the final point. It is not only the $40,000 that software vendors charge to install an electronic records system and the $10,000 to $15,000 for annual maintenance. It is the hassle factor and the often prohibitive cost of hiring staff to enter the data and to comply with new rules and regulations. When added to the time and effort already required to deal with Medicare, Medicaid, and health insurance plans, EHR requirements are the final straw.

Many doctors are seeking refuge from bureaucratic demands by retiring, closing practices to new Medicare and Medicaid patients, or seeking hospital employment.

This is ironic, since many physicians believe that new apps, such as better speech recognition or systems that translate data into narrative, will make EHRs easier to use. “Free,” government-subsidized, or cheaper models will enter the market; clinical algorithms, based on demographic and patient-entered historical information, will make diagnosis, treatment, and management faster and better.

But these features must evolve from below rather than being imposed from above. EHRs won’t be useful and physician-friendly until physicians themselves have more input into their design.

The digital revolution, and all the improvements in health care that are promised, will remain promises until the EHR is more useful—in medical and economic terms—for doctors.

Richard L. Reece is a retired pathologist and the author of The Health Reform Maze: A Blueprint for Physician Practices. He blogs about health reform, medical innovation, and physician practices at medinnovationblog.

This post first appeared at Technology Review, published by MIT.

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88 Comments on "Why Doctors Don’t Like Electronic Health Records"


Guest
Oct 7, 2011

Some of the underlying presumptions are changing, and with it the adoption curve is shifting. There are now free web-based EHRs with self-service sign-on, which has been a significantly popular model (especially for smaller ambulatory practices). Good, clean and simple UI design is also emerging (many of the products at Health 2.0 this year illustrate that). I remain hopeful that the “promises” of EHRs will become commonplace over the course of this next year.

Guest
Craig "Quack" Vickstrom, M.D.
Oct 7, 2011

Why don’t doctors like EMRs? B/c they suck. You spend less time diagnosing and treating patients. They aren’t fun. They suck much of the enjoyment out of practicing medicine. I use one b/c I have to, not b/c I want to. I spend more time interacting with the computer than my patient. They weren’t ready for prime time, so the industry went around us and got Clinton to mandate them. Of course, they could have improved EMRs until we actually wanted to pay for them and use them, but that would be too much work.

Guest
Dec 26, 2011

EHR’s that is automated, responsive, and integrated, can make clinical documentation more efficent, more accurate, and comprehensive. I believe when this happens, the doctor will spend more time on patients and less time on charting.

Guest
Ava George, MBA, CHDS, AHDI-F
Jun 25, 2014

I totally agree. I have spoken to legislators in DC about this issue. Clinical end users were never consulted about what it is that they require to communicate critical patient information from clinician to clinician with respect to an EHR. Tech companies have code writers building a product with no idea about how physicians work. These programs usually disrupt a physician’s clinical workflow to such an extent that it lengthens the time a physician or other clinician has to spend on administrative work rather than seeing patients. They absolutely were not ready for prime time. BTW….It wasn’t President Clinton who mandated EHRs…..It was President Bush in 2004 as part of his push to make all clinical records electronic and transferable.

Guest
MD as HELL
Oct 7, 2011

Bingo!!

And they suck, too.

Guest
Oct 7, 2011

I saw Dr. Reece’s post on his “Medinnovaton” blog earlier today. I’ll respond in some detail on my REC blog this weekend, but for now, this is and observation I contributed to our REC updated ONC Ops Plan this afternoon, under staff

“Challenges Requiring Support and/or Assistance”
___

“Vendor delays in rollouts of ONC CHPL certified upgrades, along with ‘bugs” (non-conformances) we find in various products, wherein MU criteria data destination/workflows do not function as advertised. Such events precipitate repeated vendor support “ticket” requests, the satisfactory upshot of which varies.

Example: we recently interacted with an REC client office (10/04/11) that had just gotten upgraded to their ‘MU Certified” EHR release. Two criteria templates were out of compliance. The vendor informed the provider that they would not modify the templates unless she could provide them with certification source documentation.

We provided the NIST test specs and OMB 15 documentation to this client, but this is NOT the responsibility of the end-users nor the RECs.

Moreover, beyond the foregoing, we find a general inadequacy of EHR MU reporting functionality and a glaring inadequacy of MU workflow documentation (with a few notable exceptions).

While we have a good aggregate grip on the MU criteria, again, consistent vendor implementation (w/respect to the numerator/denominator measures) of the requisite structured data captures remains inconsistent. HealthInsight, being “vendor-neutral,” has a particular challenge here owing to the dozens of EHR platforms we must support.”
___

I am sensitive ongoing to the criticisms expressed by doctors such as “Quack,” and, I am no unreflective cheerleader for HIT. My own Primary, a long-time EHR user (up since 2004) makes some of the same complaints.

” You spend less time diagnosing and treating patients…I spend more time interacting with the computer than my patient.”

That is to a great degree a function of the evolved reimbursement paradigm (which may be about to get even worse).

It is very complicated, all of it. I swore I would never go back to credit risk modeling,

(http://bgladd.blogspot.com/2008/12/tranche-warfare.html)

but, when I see those job openings paying base salary) 3x what I make now (to take shit in health care related blog comments about how I’m a “Socialist bent on enslaving doctors” who has no right to an opinion because I’m not an MD), it gives me pause.

Guest
steve
Oct 7, 2011

EHRs do not work very well. When they do, we will want to use them. At present, they are designed with administrative needs as a priority. I think some standardization would help, but we need some good ones before it happens.

Steve

Guest
Dr. Mike
Oct 7, 2011

“Meaningful use” has been an unwelcome brake on the progressive improvements we were seeing in EHRs. As a user of Dr. Rowley’s Practice Fusion, I know this to be true. The tens of thousands of hours they collectively must have spent making their product meet Meaningful Use guidelines could have been better spent on further improvements to the user interface and data entry. I have yet to see a product that intelligently guides the user in a way that makes data entry intuitive and seemless with the patient encounter. You should really think about hiring some computer game programers Dr. Rowley.

Guest
Dr. Henry
Oct 29, 2011

Amen:
All of the good programmers work for Google Facebook and Apple. The hacks in Bangalore are not up to the task of building a decent EMR engine.

Guest
Jan 20, 2012

The level of ignorance that this and that several other comments here reveals is astonishing. Whoever is behind the Dr. Henry moniker is no physician and appears to even lack a functioning brain.

Guest
Technologist Eric
Oct 8, 2011

As a patient I enjoy having access to a medical record I can refer to, one that is based not on repurposed claims data (data smoothed for compensation) but one based on clinically accurate attestations made by the clinician at the point of care. I like seeing this data aggregated with data taken from a lab panel, or a pharmacy order fulfillment. Before EHRs I could not access any of my medical history w/o a medical record release request, a fee, and a 30 day delay. Then I had insurer hosted web based EHRs, where I could get inaccurate data based on charge codes. These diverge enough from my actual procedures and test that I notice the inaccuracies. The EHR is not just a diagnostic chat room between provider. It helps empower the patient to research their care and communicate their history more accurately. The best of breed EHRs also allow patients to report self-care in between routine follow up visits. A tech savvy medical practice could implement a free, open source, MU certified EHR (llook at SAMHSA’s as an example). It is not a chargeable service, but electronic health records reduce the inaccuracies in patient’s pre-registration paperwork, as well as empowering them to research their care outside the walls of the practice.

Guest
Oct 8, 2011

Please think about. Most of those problems will not appear if medical students, now medical doctor, will have in their own medical training: Telemedicine and Medical Informatics. This will assure enough knowledge to drive the change, avoid engineers designing EHR and medical application, assure medical people enough trained to direct what to use, what to select, what to merge IT application.

Guest
DeterminedMD
Oct 8, 2011

“Most of those problems will not appear if medical students, now medical doctor, will have in their own medical training”

What does this mean? You are advocating that education becomes self driven? Learn how to treat people from computers?

If that is the gist of the comment, thank you for reinforcing my fears that human contact is destined to be obsolete by those who have no vision!!!

Guest
Oct 9, 2011

“their own medical training”. This means his-her training in the school of Medicine. Sorry if it was not clear enough
They need to be trained in Telemedicine and Medical Informatics

Guest

EHRs do not work very well. When they do, we will want to use them. At present, they are designed with administrative needs as a priority. I think some standardization would help, but we need some good ones before it happens.

Guest
DeterminedMD
Oct 8, 2011

Sorry, Dr Jaded and Cynical here to once again remind you in times of selfishness, laziness, and lack of investment in the community, those who want to enforce implementation of this process have an agenda that is not wholesome and pure in the end.

Putting everyone’s health information into one system is as much dangerous as allegedly beneficial. Just ask those who had loans called in by bankers back in the later 1990’s because the customers had diagnoses of possible terminal nature. And that did not even involve full computer involvement.

Computers are tools, not the end product. The generation that composes 15-30 year olds, their social and tolerance skills are eroding fast. Much in part to the complete reliance on computers, cell phones, and other technological products that allegedly minimize time and effort.

Hmmm, seems to echo the cheap and lazy comment recently, eh?

Guest
pcp
Oct 8, 2011

The problem is data entry.

Until entering accurate, relevant free-form data into an EHR becomes time and cost efficient, they’re no good.

Guest
Oct 8, 2011

Praxis EMR claims to do just this. And, it’s ONC Certified for the Meaningful Use incentives.

Guest

There are a couple of terms here that need definition:

“relevant” – To whom? Towards what purpose?

“cost-efficient” – To calculate cost efficiency, we must quantify the created value. What is that value?

Guest
pcp
Oct 9, 2011

Relevant to the patient-doctor interaction, leading to better health care.

Cost-efficient from the point of view of the doc who pays for the EHR. Unfortunately, created value for the doc is quite small.

Isn’t meaningful use moving these measures in the wrong direction?

Guest

I believe that the narrow patient-doctor interaction and its importance to better health care is currently being redefined downwards.

I also believe that cost-efficiency is being evaluated from a different perspective than the one you mention.

I think meaningful use, and the various regulations it is intended to support, are moving us in a different direction than the one you (and I) would consider right.

Guest
Anonomous
Dec 25, 2013

Right, its just more government control

Guest
DeterminedMD
Oct 8, 2011

This may not be the best post to link this comment, but I found it amongst my files recently in a discussion with a colleague about issues like these at this site per physician autonomy and how PPACA will take a giant dump on it, so I will leave it here for now and see who can understand it, much less appreciate it and understand the perpspective people like me have in hearing and reading the endless garbage of basically “screw doctors, you have no place in the health care debate as of now”:

http://www.uoworks.com/pdfs/remarks/remaMA00.pdf

It’s a good read for any and all who appreciate individuality, autonomy, and concern for the people you call patients.

Can’t wait to who actually does take the time to read it and twist it into another faux cause to cheapen medical care.

Guest
Oct 8, 2011

Question for you:

Do your believe in the rule of law?

Guest
DeterminedMD
Oct 8, 2011

Gee, I can free associate too. When a tree falls in the forest and you are there but deaf, does it make a sound?

If you are alluding I have no respect for the law, which of course is a generic term when there are assorted different laws for different arenas of our culture, you wonder why I have little respect for your retorts and lame efforts at rebuttals, but I am glad you like to annoy people and then act so holier than thou because you have alleged legitimacy as a blog author at another site. It is a shame others do not call you on your behaviors, but, they must have equal vested interests in promoting an agenda that does not really help health care, at least the providers in it.

I’ll answer this generic question per the role I have as a physician: I have never been sued as of this writing, never had disciplinary action against me by any governing body or health care institution, and strongly believe in the boundaries that are in place for patient-physician interactions.

Is my being intolerant of this process at hand called PPACA inappropriate? Perhaps to someone just coming into this site and reading my writings for the past couple of months, sure, I come across as harsh and unyielding. But, when a system that is even moreso harsh and unyielding like the bastards who concocted this BS legislation back in 09, you can’t negotiate much less even be heard being a gentleman and respectful. Good luck trying to be the mensch with the turds that are entrenched incumbents in DC.

Oh, by the way, that wonderful gentleman from Nevada who is the biggest hypocrite of his group of Senator colleagues, what a genuine moment this past Thursday evening of how to manipulate the system for his party’s own good. Read up on why it is called a nuclear option, and how this asshole was so vocal how wrong it was when Republicans threatened to try it back in 2005. People like him can’t die fast enough for me, because he has no humility or grace when to know to retire. At least Steve Jobs had the decency to step down and name a successor before he died, because he had some sense to the adage “the needs of the few outweigh the needs of the many”.

Which is why I forward outside comments like the above link. Not for you, Mr G to understand nor appreciate, but my colleagues who’s collective silence is similar to that of the above tree falling . Asking politicians to take the proverbial lead in health care decisions from those of us who actually embrace the terms and expectations of being providers is like asking thieves to design the security systems of banks and other financial systems. Wow, after writing that last sentence, a true analogy for me!

Maybe if the tree fell on the collective heads of the AMA members who agreed to support this moron in the White House, maybe those of us far away might hear their screams. Not that I would rush to their aid though.

Memo to those of you, watch the original version of “Logan’s Run” from the late 1970’s, that will be the overall example of Health Care for the US circa the later 2020’s. Because the elderly will have been effectively ignored and allowed to die off overall, and then those who have any chronic illness will be encouraged to die for the greater good of the healthy.

Sounds ludicrous? Why is it art imitates life, and silly movies or Sci Fi books from decades ago end up being blueprints for the current times? Maybe some people sense the nature of humans. Especially anticipating that of those in power and control. We are a corrupt species until proven otherwise. But, naivete has a strength. Yeah, but being blind to have stronger hearing is not an advantage to me!

Just watch out for those proverbial branches falling before the trunk!

Guest
Oct 8, 2011

Y’know maybe you oughta see that Jonathan Rosman psychiatrist guy you cited. You have some blaring issues.

It was a simple question.

Give me 5 minutes of Socratic with you (or any Randianista), and I will leave you in deductive and inferential rubble. For someone who has such repeated little regard for my views, you sure keep taking the bait.

:)

Guest
DeterminedMD
Oct 9, 2011

Wow, you tell me I should seek out psychiatric help and then finish with “Give me 5 minutes of Socratic with you (or any Randianista), and I will leave you in deductive and inferential rubble.”

I would suggest you consider a session or two yourself, but, narcissism on the scale you write is not treatable. At least no drugs will have any effective impact. Well, maybe Thorazine, as some levels of Narcissism do reach grandiose scales of psychosis.

Umm, we are waiting for your “OK, stayed tuned, this is gonna be a doozy. I’m no only gonna read it (I found an editable copy, even though he tried to “copy protect” it; took me all of 5 seconds), I’m gonna flowchart the “logic” so there’s nothing to “twist.” ” Personally, I do sincerely hope after you read it, you did realize that the author did have legitimate points about autonomy that were fair and reasonable.

Besides, if you attack it as mercilessly as you allude to try, would this alienate your physician buddies? Me hopes your silence is one of responsible reconsideration.

By the way, did I answer your question about my respect for the rule of law as you first inquired?

Guest
Oct 9, 2011

“Personally, I do sincerely hope after you read it, you did realize that the author did have legitimate points about autonomy that were fair and reasonable.”
___

All I see thus far is the std Rand Rant.

“realize that the author did have legitimate points about autonomy that were fair and reasonable.”
___

Yeah, of course. It’s called “Even A Broken Clock Is Right Twice A Day.”

BTW, this is interesting:

http://www.bgladd.com/PDF/AynRandBioReview.pdf

You’re waiting, ‘eh? I thought you didn’t give my assertions any credence?

Keep waiting. It takes a bit of time. This one took me about 40 hours:

http://www.bgladd.com/PDF/JAMA1994SinglePayerProposalAssessment.pdf

“By the way, did I answer your question about my respect for the rule of law as you first inquired?”

No. It was a trick question anyway, given who you cited.

BTW, thanks for the precise psych dx (I guess I’m a 298.8, psychotic NOS). At least YOU may be able to bill for it (let’s call it a “portal based TeleMed e-Visit”. e-Rx me some Ativan along with teh Thorazine while you’re at it, OK? Generic would be fine).

:)

Guest
Oct 8, 2011

“It is a shame others do not call you on your behaviors”
___

It couldn’t be much easier to do. I don’t see how I could be any more public. Would my long-form Birff Certificate help?

Guest
DeterminedMD
Oct 9, 2011

Oops, two mistakes in my above rant:

1. It should be “the needs of the many outweigh the needs of the few” and
2. the Logan’s Run comment issue of example where it may be a reality of our culture is probably moreso likely in the 2030’s, gotta give it a full generation to have the impact, as well as let the current generation that is over 65 to be eradicated, per the Logan’s Run premise.

Re-reading this today, I still stand by it. Politicians continue to reveal their true intent since PPACA was passed. It is either their way, or no way. At least people who are passionate about their concerns and philosophy who equally respect people who differ should have a choice by offering the highway.

We have alleged leadership from both sides of the aisle who only want to crush and destroy any opposition. Really, this is what you folks want and appreciate in this type of leadership? I mean, really, do you readers here not see what is the agenda?!

Blind faith really is that, blindness of strict dogma or naivete is a dangerous weakness. Leadership is earned and constantly reappraised as ongoing. Sometime, terms of an elected position are not limited to a time frame. Isn’t impeachment applicable to all posts of government?

Oh yeah, that requires insight and judgment of alleged colleagues. Scrap that!

Guest

Dr. D., I’ve been reading your comments here since the days you were Exhausted and I don’t see how you can support the views expressed in that article. The person who wrote that article is all about money, openly and explicitly.
I understand how many docs are concerned with government’s (and insurers’) intrusion in the way they provide care, and I understand the concerns that politicians today are largely bought by big interests, and to a large degree I do agree with both concerns. What I don’t understand is the cold blooded disregard for people that don’t bring in revenues.
Do you really consider your profession to be morally and ethically equivalent to selling cars or fixing toilets?

Guest
Chronicallyill
Feb 28, 2012

Determined MD. Thank you for caring for your patients. BobbyG sounds like an employee of the government or lobbyist for some health insurance company. I just pray more doctors still care about the oath they took. I am working hard to find my local congressman to protect my patients bill of rights (puke). God help us all especially the sick ones.

Guest
Oct 8, 2011

Quoting you earlier”

“Sorry, Dr Jaded and Cynical here to once again remind you in times of selfishness, laziness, and lack of investment in the community…”
__

OK, stayed tuned, this is gonna be a doozy. I’m no only gonna read it (I found an editable copy, even though he tried to “copy protect” it; took me all of 5 seconds), I’m gonna flowchart the “logic” so there’s nothing to “twist.”

:)

Guest
Technologist Eric
Oct 8, 2011

Free-form text can be entered in a number of EHRs (GE Centricity is an example). If yours does not support it out of the box, ask how much it costs to add a field for the entry and reviewing of free-form text. It is not going to meet the long term requirements for quality of care reporting to CMS. Free-form clinical documents are extremely expensive and error prone to parse into something you can measure against quality of care metrics.

Guest
Oct 8, 2011

Praxis EMR claims to be able to parse and save structured data elements from free-text progress notes into SQL tables. I’ve only seen it in the clinic once (one of my REC clients).

They got ONC certified, insofar as that says anything.

Guest

It is very helpful fort me and this is a good article that I saw,thanks for sharing!

Guest
Oct 9, 2011

“The person who wrote that article is all about money, openly and explicitly.”
___

Well, Margalit, that’s what the Cult of Randianism is all about. It is pretty much unreflective beyond that nominal point — hence all of the bely-laugh internal inconsistencies and endless maze of non sequitur potholes (shovel-ready?) along its Road to Reason.

And, we may be about to yet enter one of those eras where the “money” will once again be severely debased, perhaps violently so. Read Michael Lewis’ new book “Boomerang.”

From the Rand bio I cited (which looks to now be in Moderation purgatory):

“…[Rand’s] work may be easy to ridicule, but it has appealed to gen- erations of readers precisely because it seems to articulate something true about a society in which there is little sense of common purpose or regard. Should there be any lingering shame or sadness at our modern Gilded Age, at the material gaps that place some in luxury skyscrapers and others out on the streets, she encourages her readers to renounce that discomfort as the true immorality. Her work offers a way of making sense of a profoundly unequal society, of making it tolerable, even virtuous. Is the arid world she describes, in which all common creativity and sense of intellectual tradition has been reduced to individuals acting alone, not reflected in the empty nature of our public life? Do we not live in a world divided between winners and losers, between people who seem to live as Supermen and those who are treated as though their lives have no value at all? If societies get the thinkers they deserve, it is troubling to think that Rand is ours…”

To the committed Randian, there IS no concept of a “commonweal.” Humanity consists merely of the aggregation of molecular, autonomous, darwinian socioeconomic You’re-Not-The-Boss-Of-Me transactional dyads.

It’s just silly. An epistemological hairball.

BTW, she had me at “Altruisim is the greatest Evil. It requires the sacrifice of the competent to the incompetent.”

Well, I guess that rules out parenting.