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Why Doctors Don’t Like Electronic Health Records

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By RICHARD REECE, MD


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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82 replies »

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  11. 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.

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  17. 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.

  18. I agree, adopting an EHR comes with a lot of training, implementation, long grusome hours of inputting new data, etc. However, what many doctors don’t realize is finding the proper vendor is a major part of EHR adoption. Once the vendor helps you transition from your paper records to the EHR, there is definitely a quick ROI. You will free up more time for your staff because all of your patient records will be one click away. And even more so, you will be able to put a better focus on patient care. Finding all of the patient’s useful information on the screen directly in front of you in a quick easy manor will be able to help you better diagnose that patient. It is up to the doctor to ensure that they still make direct eye contact with their patient, make them feel comfortable in the room, etc. EHRs are a GREAT tool for more efficient pratices in the future. EHRs are the future and they will continue to grow with your practice for years to come. Again, adopting an EHR can be a struggle and seem overwhelming but many people fail to realize is the importance of finding the right vendor. The vendor and the EHR should be offered as a package deal and they should both be able to meet your needs and put your fears and hesitations to rest.

  19. 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.

  20. 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.

  21. 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.

  22. Great example of why people shouldn’t be so quick to get rid of employer sponsored coverage. Right now employers are the only ones looking to hold down cost and improve employee health on a consistant basis.

    Yes some employers will just buy the cheapest plan or not offer coverage at all but the vast majority of employers are trying to do whats best for their employees and help them. Not that they get any credit or appreaciation for it.

  23. Let me offer a patient perspective. Not necessarily an experienced patient, fortunately, but an occasional patient, who has seen a variety of doctors over the years.
    I have two bad knees. Not severely bad, but only because I work to keep them functioning. I had my most recent surgery about eight years ago. Every time I have had some knee ‘difficulty” – maybe three or four episodes since that surgery, i have returned to the same practice, based in a respected university teaching hospital,
    Each time they always have my demographic information correct, even my insurance information, yet absolutely no evidence whatsoever that they ever did anything with my knees. I have learned to bring my own images, which baffles me. and to have to start from scratch describing a medical history of 30+ years of ACL-less knees.
    Likewise, my wife use to think it was important to return to the same imaging center for her periodically required diagnostic images – until she discovered they don’t keep the images either.
    I would like to go to a doctor and know that he or she knows, or can find out, when I had my last tetanus shot, or what immunizations my children have had and still need even when I move to a different town. i don’t have to want to wait five+ minutes while they fumble through a ream of paper trying to figure out what prescription they gave me the last time I visited. And without e-prescribing, how do they expect to know whether I filled or took the prescription.
    I picked my most recent doctor, in part, because the practice uses computers. i cannot speak to its ease of use from the docs perspective. She hasn’t complained to me. But she walks into the examining room with a small laptop and can quickly lookup anything she needs to know about my previous visits.
    I yearn for the day when all my doctors have access to the same medical history.
    i administer a large benefit plan and we hire a disease management firm. Why should an employer sponsored plan be purchasing “disease management”? Because physicians don’t seem to operate in an environment where they have access to all of the information needed about patient care. so disease management firms have learned to mine claims data – hardly perfect – to find out when members are doctor shopping for certain prescription drugs, when they are seeing different doctors for multiple conditions with no care coordination whatsoever.
    I don’t think we should be in that business, but docs aren’t, and as long as I am getting positive feedback from our employees and a return on our investment, we will continue.

  25. Really, NPs just want their alleged piece of the pie, and should they get more than they bargained for, they will find out the adage, “power corrupts, and absolute power corrupts absolutely.”

    I just love the looks of astonishment and incredulity, when I remind the ones who want my job responsibilities, that there will be changes in malpractice coverage once the insurer finds out what they want to do in clinical care interventions. Ooooh, what did you all miss, NPs, when the adage “with great power comes great responsibility”? Every body who is not an MD wants all the perks and none of the accountability.

    It’s like what a supervisor in residency told me: everyone wants to be the doctor until the crap hits the fan, and then who is out of the room first to avoid the trajectories? Not the doctor or patient!!!

  27. Our health care system does not work. Our system costs more and produces less results than most industrialized countries. Our system is consistently rated at the bottom. Our morbidity and mortality rates are high and we rate very low in treating illnesses. If the system were not broken, there would be no need for a fix. Unfortunately the government is having to step in and enforce changes and controls. I would prefer to see our current system fixed and reformed prior to expanding coverage to more Americans but the fix we got was the Affordable Care Act.

    Insurance companies are making record profits, healthcare corporations such as for profit companies that own hospitals are making profits and in some cases, physician incomes are extraordinarily high. Something has to give. If the main powerful players, the doctors, hospitals, and insurance companies would have been playing fair and managing the system with positive outcomes, then reform would not be necessary.

    I dont understand any provider, doctor, physician assistant, nurse practitioner, dentist, optomotrist, etc, being against reform that leads to positive patient outcomes. The government is providing a lot of money for providers to transfer to EMR systems. We have to put the patient first and what is best for them and set aside some power and control and possibly some income in order to do that. We simply cannot afford to continue in the current direction with healthcare. The results of our health care system are terrible and an embarrassment and this is a known fact despite the huge cost. There is rampant abuse and corruption from upcoding to changing diagnosis to unnecessary procedures and admissions for profit. If physician autonomy and income goes down and this leads to people leaving the profession it will make way for a new group of providers going into the profession because they want to provide quality care and are willing to do what that takes, even if they dont have 100% autonomy or mega incomes.

  29. When I had to set up guardianship on my late Dad in 2008, the lawyer’s rate was $300 per hour (she was a highly recommended geriatrics law specialist). The whole ball of wax ended up costing about $4,300.

    More later; gotta run.

  30. Well, thank you, but no one deserves $300 an hour unless one can guarantee a cure or is exceptional at saving lives in trauma/acute care settings.

    some people have the work ethic and focus on patient care that may well justify a reimbursement rate that is extraordinary. Most doctors who do so more often aren’t looking for the dough though, they really like seeing people survive and get better.

    There is no one easy tip to define what a physician is like instinctively, but one I note more often is a hint of attitude: what kind of car they drive. People who do care for the sake of doing care drive a realistic, prudent vehicle. People who are superficial and vain, well, you know what type of vehicle they own. Me, I bought my most expensive car this past year, a Hyundai Santa Fe. Will never pay more than $20 K for a car the rest of my life, per inflationary adjustments. You think about how you conduct yourself in the community, it shows in the office too.

    Just my opinion.

  31. “DeterminedMD says:” October 10, 2011 at 6:12 am
    “Is this a genuine supportive statement or usual sarcasm without the fonts?”
    ___

    I meant it.

  32. Is this a genuine supportive statement or usual sarcasm without the fonts?

  33. By the way, a Nurse Practitioner telling doctors to answer to others. What, your specialty? I can’t wait to find out when malpractice insurers catch up with your demands for more intervention skills, and then the premiums shock you all into what real accountability costs!!!

  34. “I do not agree with doctors or any other health care providers being opposed to “being told what to do” when what they are being told to do is for the best of their patients, their profession, the health care system, and their country. ”

    Really? Based on who’s supervisory experience and accountablility? Politicians? Insurers? Patients?

    People who write these kinds of positions better watch out, because I don’t know what physicians Steve hangs out with, but I know several colleagues who are at least a dozen or more years from retirement who are contemplating it now, and others who are just going to go to a cash only practice and see how it plays out.

    You all think doctors should answer to non-clinician demands? Good luck with that, but, the antiphysician mentality that comes out here sure explains why such ignorant and dismissive rhetoric gets traction. After all, we are sure seeing a mob mentality up in New York, and how easy it is for those who are predators to get the menials to do their bidding.

  35. “Health care providers seem reluctant to check these databases to see if their patients have been getting controlled drugs from other providers, known as doctor shopping.”
    ___

    See

    http://regionalextensioncenter.blogspot.com/2010/11/first-do-no-hold-harmless.html

    In particular my citation of the Broulliard paper “Emerging Trends in Electronic Health Record Liability”

    Moreover,

    “Sometimes we have to do things that are time consuming or inconvenient if its in the best interest of others.”

    Too often there is a compartmentalization of the FTE time burden, confusing the nominal with the aggregate. Clarifying this is part of the work with which I am charged.

  36. I am a nurse practitioner in private practice and I have a web based EMR for notes, billing and e-prescribing. It is more time consuming to use an EMR as far as having to go to different screens and enter data. It was much faster writing in a chart, but charts get lost, and they take up too much space. I started my practice with paper for two years and then transitioned to an EMR which entailed scanning in all the records. I was just starting a part time practice at the time so I only had a few hundred records that had to be scanned in. For providers with huge practices, it would take a lot of time and money to transfer over all records. Its best to start out that way. I do think that EMR’s cause you to do better more thorough documentation and can prevent medical errors and are more efficient.

    I have heard the concerns about privacy and safety when using web based EMRs which are less expensive and require no equipment but I dont have that concern and it is the wave of the future. I believe that in 2014 the government will start taking a small amount of money away from providers who do not use EMR’s who take medicare. That has causes some of my colleagues to not want to accept medicare patients. Many doctors now have quit taking medicare patients let alone medicaid patients because they do not believe they are adequately reimbursed for this. I dont agree with that but that is their prerogative.

    I do believe that the medical field has become more of a business than a helping profession and is money driven and also corrupt in many ways. I consider myself a conservative but I am in favor of health care reform because I believe that change needs to occur due to rampant abuse. I do not agree with doctors or any other health care providers being opposed to “being told what to do” when what they are being told to do is for the best of their patients, their profession, the health care system, and their country.

    Another example of this is prescription drug monitoring programs. Health care providers seem reluctant to check these databases to see if their patients have been getting controlled drugs from other providers, known as doctor shopping. Only seven states require providers to check the databases. Many doctors are against regulations requiring them to check the database event though doing so is proven to reduce prescription drug abuse. Sometimes we have to do things that are time consuming or inconvenient if its in the best interest of others.

  37. Interesting.

    From my late daughter’s story:
    ___

    “Money-grubbing, egotistical docs”

    Late one quiet evening on the 4th floor at Brotman, a double-shift weary Dr. Mittleman and I leaned on the counter at the nurses’ station and mused at length upon some of the more absurd alternative therapy allegations. Responding to the notion that his profession was raking it in while suppressing the “competition,” he quietly countered “right; I’m getting rich on the sixteen dollars a day I get from Medi-Cal for seeing your daughter.”

    Here was a man repeatedly to be found perched on the edge of Sissy’s bed at odd hours, talking with her for 30-40 minutes at a time– a temporal generosity he shared time and again with me in the halls as we discussed the more technical aspects of her situation. This is a man who continues to field and return her calls, sees her on a moment’s notice, and jawbones the Medi-Cal bureaucracy on her behalf, even though she is technically no longer his patient.

    I recently emailed Dr. Mittleman to express my gratitude, joking that “should they ever decide to start cloning the best doctors, I’ll be by your office to pick up a DNA/tissue sample.”

    Likewise for Dr. Sherry Wren, the swaggering, 5’3″ supremely confident surgical wizard who saved Sissy’s life in April of 1996, and who continues to stay in touch with us. Likewise also the innumerable doctors, nurses, therapists, and support personnel who have rarely failed to accord my daughter the utmost respect and compassionate, knowledgeable care throughout the past year and a half– many of whom will earn less in a lifetime than Dennis Rodman was debited by the NBA last season for unsportsmanlike buffoonery.

    Every discipline has its share of the “arrogant and narrow-minded,” but I have mostly found mainstream health care professionals to be a dedicated, unpretentious, and self-deprecating lot quite aware of the limits of their knowledge and the risks of presumption. Once, during a series of health care quality improvement seminars I attended at Intermountain Health Care in Salt Lake City during my Peer Review tenure, a speaker– himself a noted pediatric surgeon– wryly observed that “the best place to hide a hundred dollar bill from a doctor is inside a book.” The Director of the seminar series, Dr. Brent James of IHC (and a Fellow of the Harvard School of Public Health), noted in our opening session that physicians would probably admit– off the record, of course– that perhaps only 10% of their clinical decisions made during daily practice could be traced to the peer-reviewed scientific literature. Dr. James also made the droll observation that, were you to walk into the typical medical adminstrator’s office, “you’d be much more likely to see copies of the Wall Street Journal rather than the New England Journal strewn about.”

    What can one take away from such remarks? First, the many physicians I have come to know in the past few years are in the main acutely sensitive to the problems of clinical conceit and “paradigm blinders.” Indeed, the Utah pediatrician’s”$100 bill” wisecrack was offered to an audience of doctors and their allied health personnel during quality improvement training. Second, the body of peer-reviewed medical literature does not constitute a clinical cookbook; even “proven” therapies– particularly those employed against cancers– are generally incremental in effect and sometimes maddeningly transitory in nature. The sheer numbers of often fleeting causal variables to be accounted for in bioscience make the applied Newtonian physics that safely lifts and lands the 747 and the space shuttle seem child’s play by comparison. Astute clinical intuition is a necessary component of a medical art that must, after all, act and act quickly– so often in the face of indeterminate, inapplicable, or contradictory research findings.

    Finally, with respect to Dr. James’ Wall Street Journal quip, the capitalist imperatives within which health care clinicians must operate are, in the aggregate, neither of their making nor under their control. Moreover, blanket indictment of the profit motive as necessarily inimical to optimum medical care and research is a rather simplistic notion. Strategies aimed at maximizing investors’ net returns probably spur at least as many medical advances as they inhibit…”

    http://www.bgladd.com/1in3/
    ___

    But, to JohnGaltMD — uh, “DeterminedMD”, I’m an anti-physician ignoramus out out enslave doctors.

  38. ““And it is the best doctors, the most dedicated and those least ready to relinquish their independent judgment, who have been the first to leave the practice of medicine when doctors’ rights were trampled on.”

    That is most certainly not what I have seen. First, not that many leave. Secondly, those who leave over perceived rights issues have all been fruitcakes. Almost always a really crappy doc also. Every one.

    Steve

  40. “yeah, we should get paid $30 an hour, because,”
    ___

    No, to me, more like $300/hr base, I would say.

    “Umm, how about you spend twelve or more years after HIGH SCHOOL and learn a professional training that makes you responsible for people’s lives, literally. And per your specialty training, carry a phone or pager around for at least a few days a week and risk being called to handle medical matters at whatever time of the day.”

    How poignant.

    http://www.bgladd.com/NoCryingInHealthCare.jpg

    Yeah, I know; you’re pissed (justifiably) and confused. You are not alone.

  41. Dr. D.,
    You are reading things that are not there. There is no need to look for interpretations in what I write. I usually call it as I see it explicitly.

    1) Statement: Physicians as a group are not living in poverty. Does this statement imply that they should live in poverty? Not at all. Does it even imply that they should be making less money? Nope, and neither does it imply that they should make more. It is a plain statement of fact.
    My opinion, as strange as it may seem to you, is that with the exception of primary care, which should be paid a lot more, most docs are adequately compensated.

    2) Yes treatment is a matter of choice, and in the cancer example the choice is get treatment and maybe live, or don’t get treatment and die. I guess you can call it a choice, but it is very different than most choices people have to make in the course of normal life, and it is definitely different than fixing one’s toilet, or not. And IF and WHEN a patient makes that choice and comes in for help, it seems unfair to reserve the right to charge as much as possible just because life, or excruciating pain, may be in the balance. And this is exactly what the author is demanding as his right. Those who have the cash, will get the treatment. Those who don’t….oh well, who cares….
    You can’t possibly agree with this, right?

    3) Doctors should not be stripped of income. This goes to point #1 above. There is a huge difference between stripped of income, vow of poverty and the simple requirement that a few greedy individuals with a peculiar attitude should not be allowed to gauge prices.

    I would like to keep the PPACA out of this. I have my own problems with the Act but that is irrelevant here because the article was written way before that, so the only rage the author could have had would have been against the sheer existence of insurance. Of course nobody was forcing him to accept any insurance, but I guess that idea didn’t seem lucrative enough.

    And by the way, not calling the author a doctor, is not a shot at doctors. It is a sign of respect.

  42. I have issues with some of your comments per the 12:44 posting:

    1. “I think I would have shared the article’s outrage on payment levels if the medical profession was largely comprised of paupers, but it is not.” Seems you are basically saying we as physicians are rich, overpaid people. Umm, how about you spend twelve or more years after HIGH SCHOOL and learn a professional training that makes you responsible for people’s lives, literally. And per your specialty training, carry a phone or pager around for at least a few days a week and risk being called to handle medical matters at whatever time of the day. Gee, when you hear it that way, yeah, we should get paid $30 an hour, because, hey, same thing like being a tow truck operator.

    2. “Somehow, particularly during this economic downturn, demanding “freedom” to extract more money from the already impoverished 99%, and suggesting that those who cannot come up with the cash should have the “freedom” to pretty much go to hell, seems a bit in bad taste for a doctor.” Extract more money from people. Man, I must have missed the muzzle prints on patients’ heads when they come to see me. Last I checked, treatment is about choice, unless you are in an acute trauma or medical emergency like an MI or stroke. Even cancer is not an acute care issue, yet the way you wrote this sentence, every one who walks into a doctor’s office has us forcing them to come to us and then we stick our hands in their wallets/purses and rip the cash out. How freakin’ insensitive this comment was by you!

    3. “He is standing up for his “right” to make as much money as possible, without having to consider the consequences of his actions to anybody but himself.” Wow, that is quite the interpretation of what Dr Rosman wrote, and by the way, another shot at physicians by saying you can’t call him a doctor. Sure, there are statements about making an income, but, why is it a lot of you here think that doctors should just be stripped of income while other professions that literally do not impact on peoples’ lives at a moment’s notice can still pursue sheer capitalism and have no accountability?

    Face it, your comment can be easily interpreted we should take a vow of poverty and be thankful we are still allowed to provide care. I thought you to be a bit of an ally, but after today’s comment, forget that!

    Nate below was on the mark, PPACA can be passed without anyone in the halls of Congress having to consider the consequences of their actions, and we should all genuflect and pray for our leaders’ well being and ongoing ideology. Wow, another example of hear the lie enough it becomes the truth.

    Are you out on the streets near Wall Street now? Sorry, I was raised to be a fiercely independent person, and found the profession of medicine to work for my type of philosophy and desire. And guess what, a good portion of my patients seem to appreciate my attitudes and expectations.

    Good luck finding doctors embracing the desire to work honestly and earnestly should PPACA survive the Supreme Court. You all will get the care you deserve should politicians keep lowering the bar!!!