How I Learned to Stop Worrying and Love the (EHR) Bomb

Remember the fear mongering rhetoric about weapons of mass destruction and all sorts of other bogey men that sometimes led to war death and true destruction and other times to just animosity, hatred and counterproductive waste of time and resources?

This is exactly what we are witnessing today in Health Information Technology (HIT). Granted this is only a sideshow, while the main stage is occupied by the unprecedented Federal push to computerize medicine, but it has a very shrill voice and it seems to be confusing many good people. There are many legitimate questions that need to be asked, many strategies that should be debated, many errors that must be corrected, but the unsubstantiated, dogmatic and repetitive accusations directed towards HIT in general, EHR in particular, and chiefly at technology vendors and their employees, are borderline pathological in nature.

To be clear here, there are many practicing physicians and nurses who are either forced by an employer to use an EHR they dislike, have tried to use an EHR and didn’t enjoy the experience, or are opposed to the EHR concept on principle because the software has no return on investment in their situation, is not “ready for prime time” or is too closely aligned with the goals of the Federal government. These are all valid points of view and should be listened to and considered by policy makers as well as technology builders, and I have to confess that I do agree with much of what these practicing folks write and say, and as I said many times in the past, practicing physicians, i.e. those who see patients every day, are dangerously underrepresented in all HIT policy and technology decisions being made now at a federal level. Unfortunately, the practicing doctors’ message is being obscured and tainted by the “naysayers who predictably and monotonically chant the “HIT is evil” mantra at every opportunity” (quoting the famed HIT blogger, Mr. Histalk). These “self-proclaimed experts” and their incendiary and largely self-serving monologues are making it very easy to dismiss legitimate problems present in HIT policy and technology.

The #1 allegation against EHRs and those who build them is probably the one contending that EHRs kill people. HIT is supposedly an unauthorized human subject experiment which should be halted due to so many deaths and injuries. There is no evidence to support this assertion. Yes, there are several deaths documented, which have been associated with EHR software in one way or another, all in hospitals, but there is no documented evidence of mass injuries. The ugly truth is that people die in hospitals due to preventable errors of all types. They died before EHRs were introduced and they are still dying at similar rates after EHRs were installed. For every error attributed to software malfunction, there is a parallel error that can be attributed to lack of software or utilization of paper charts in general. For example, a software bug could cause records to end up in the wrong chart. How many times do paper records get filed in the wrong chart? How many times do paper records get misplaced never to be found again? How many times do paper charts disappear for long periods of time?  Of course since paper is a passive medium, all errors arising from paper charts usage are directly attributable to users. When an EHR is used, some errors, not all and not most, are attributable to the software. Ergo, EHRs kill people while prior to EHRs people killed people. Net effect is the same, although fixing software bugs is a lot easier than remediating people’s error prone behaviors.

The #2 inflammatory allegation is squarely directed at the business entities that build and sell EHRs, and individually towards anybody associated with IT, whether at a hospital level or a vendor level. Supposedly, these dim-witted IT folks have no understanding of medical practice and a complete disregard for patient safety and human lives. I have no doubt that some IT folks would not score very well on Mensa tests and others may have little interest in anything other than their paycheck, and this is true about any randomly selected group of people, including clinicians. However, EHR vendors are for-profit technology companies, and as such have an overriding interest in creating revenue. You do not benefit your long term top-line by purposely selling defective products. Suggestions that EHRs should be produced by non-profits are a bit naive considering that this is health care we are talking about, and we all know how selfless, charitable and patient safety oriented other non-profits are in this industry. I would also like to point out the few and far between health care providers who are willing to treat Medicaid patients due to financial and business considerations. How are the sacred patient safety and human life considerations ranked by those providers? I would assume they come in right after staying in business, keeping the doors open and perhaps even an acceptable profit level. EHR vendors are no different.

As to hospital IT folks, the ones I had the pleasure of meeting always listed patient safety as their main concern. Was it just lip service? I don’t think so, but all I have is anecdotal evidence. In any case, the incompetence and profit concerns of hospital administrators who drive EHR deployments in hospitals and health systems, to the extent that they exist, are not indicative of HIT being murderous or evil. They are indicative of the need for transparency and learning from those that manage to deploy the same HIT tools successfully, and those do exist.

Moving on to #3, we find the widespread platitude contending that EHRs should be built “by doctors for doctors”. Guess what? Many are, and it doesn’t make those EHRs any better. Amongst the larger EHR vendors, there is none that does not employ physicians and some have dozens of MDs on staff and hundreds of other clinicians. Many medium and smaller EHR companies were founded, and some are still owned, by physicians. There are two issues here. One is that most physicians fully employed by technology companies are not practicing anymore and I am not certain they ever did after residency. I have personally witnessed multiple times the huge disconnect between the professional IT physicians and those seeing 30 patients each day. Couple that with the “I’m a doctor, so I know best” attitude, and you are guaranteed an academic product that will have little value in the “real world”. The second issue is that most physicians know as much about IT as engineers know about medicine. With very few exceptions, commercial EHRs should not be built by doctors as a side hobby. They should be built by professional software designers and builders with extensive input and guidance from customers, just like quality products are built in all other industries. And by customers, I don’t mean “ivory tower informatics experts” who happen to have an MD after their name. I mean hard working, six days a week, frazzled and discouraged, practicing doctors and nurses.

Finally the #4 issue is the perpetual cry from various quarters that EHRs should come under FDA supervision. I strongly agree. Any instrument used in the delivery of medical care should be supervised to an appropriate degree, and maybe such transparent supervision would put an end to the fictional assertions that EHRs are guilty of mass murder. Done right, FDA supervision will definitely help folks make better product choices and deploy and use EHR technology in more beneficial ways. With the recent proliferation of “certified” EHRs, triggered in large part by the glow of HITECH money, FDA supervision could also serve to separate the wheat from the increasing amounts of chaff. It is also useful to remember that people are killed every day by FDA approved drugs and devices due to improper use, human error, negligence, criminal intent and product faults that the FDA missed.

In conclusion I would be remiss if I did not mention the multiple legitimate complaints regarding EHR usability and utility. While there is much work to be done, many errors to be addressed and much technology innovation to be applied, the form and function of EHRs is ultimately dictated by the environment in which they are used. The business of medicine (a.k.a. billing) dictated most of the box-clicking nature of older EMRs and the new population health, cost cutting and research focus emanating from the Federal government will just increase the demand for structured data elements and the accompanying clicking on boxes. EHR vendors will build whatever customers are willing to buy. It is infinitely easier to build an EHR without click-boxes and templates, than it is to build one that records and maintains hundreds of templates, customizations, vocabularies, cross-walks, guide-lines, protocols and analytics to slice and dice everything. Vendors would be more than happy to just give you a blank text box where you can type, scribble or dictate to your heart’s content. But guess what every single physician looking to buy an EHR is asking right after the price question? “How many templates does your system have for my specialty?” The structure of EHRs is a symptom of quite a different problem and it will not be resolved until the root cause is addressed. So the lunatic fringe notwithstanding, EHR vendors are not out there to torture you or kill your patients. They are out there to sell you products and services and make some money in the process – just like Apple, Microsoft, Google, IBM, and you – and they build the products based on what the customer says he wants and what the Government says they must.

And no, you don’t have to buy one if you choose not to………

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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25 replies »

  1. Great post. I have to emphasize you point that the tail (billing) is wagging the dog (legible documentation of the patient’s story and the reasons for the treatments chosen). It is absolutely tragic that millions (billions?) of dollars of software development and physician practice time have been wasted on E/M coding which creates obfuscation and impairs clinical communication.

    • Unfortunately, I don’t see those CPTs going away any time soon, so there will be many more millions going down that same drain.
      Right now, I’ll be happy if those who define clinical quality measures and requirements for structured data elements collection learn the lessons from the billing debacle and don’t add insult to injury.

      • Well, to do a “cut and paste”… 🙂

        “…technical policy, standards, and incentives are necessary but not sufficient to drive meaningful use…Ultimately the business structure, not the technical architecture, of the industry will determine which cost, quality, and access objectives are feasible in health care…”

        Realizing Value from Health IT: A BCG Response to the PCAST report


  2. Great post, Margalit. You write that “With very few exceptions, commercial EHRs should not be built by doctors as a side hobby.” As a formally-trained medical informatician (Hopkins, Columbia) and practicing (half-time, private practice, but only ~20 patients per day) family physician, I hope to be considered among the exceptions. I believe that deep informatics knowledge combined with clinical experience is the right combination for high-quality clinical software. Then again, I’m biased…

    • I don’t think you are biased. I think you are probably the dream clinician for most honest EHR builders. The trick is to continue practicing as you work on an EHR. Sadly, many docs start out that way, but somewhere along the road, they give up the practice, or put it on a back burner. I do understand why, but I wish they didn’t.
      I had the privilege of working with an emergency physician once and because of his hours, and his sense of priority, it was always a challenge to get together, but boy, was it worth it…

  3. Thanks, Dr. Levin. I actually think that Meaningful Use is more of a wish, a hope, a promise than anything else right now.
    True, it is aimed at data collection and as far as I can tell the government is pretty clear that research is the chief agenda through which they hope to achieve the promised benefits.
    Having seen plenty of the “data” collected, I have serious misgivings about its fitness for quality research, but perhaps that will improve too.

    On the PCP front, I don’t think computers are enticing for today’s kids; computers are assumed.
    Either way, here’s another scary survey saying that 40% of PCPs are contemplating retirement.
    That’s what we need to fight, I think….

  4. Margalit: So nice to have a sane voice in the crowd. I tend to take the “middle road” in these discussions.For me the EHR is a tool, and doctors always like their specific instrument for a task. It is foolish to believe one size fits all. Meaningful use in primary care is not the same as in surgery, or ophthalmology. MU is in the eyes of the mandate, not even the beholder. It is a means of coercing the system to supply thee bean counters with numbers that they judge to be useful for whatever purpose. Not only that but the government is now highly prejudicial thinking they will ‘inspire” more PCP to offset increasing demand for services. There is at least a five to ten year lag increasing numbers of doctors. It starts with the first year of medical school and the time it takes to educate a physician….at least 7 years. The government uses HIT and EMR on the bully pulpit circuit.

  5. Margalit: So nice to have a sane voice in the crowd. I tend to take the “middle road” in these discussions.For me the EHR is a tool, and doctors always like their specific instrument for a task. It is foolish to believe one size fits all. Meaningful use in primary care is not the same as in surgery, or ophthalmology. MU is in the eyes of the mandate, not even the beholder. It is a means of coercing the system to supply thee bean counters with numbers that they judge to be useful for whatever purpose. Not only that but the government is now highly prejudicial thinking they will ‘inspire” more PCP to offset increasing demand for services. There is at least a five to ten year lag increasing numbers of doctors. It starts with the first year of medical school and the time it takes to educate a physician….at least 7 years. The government uses H

  6. I am a medical group practice manager who has implemented one EMR in a surgical specialty setting, and am getting ready to do another. I always enjoy Margalit’s posts because they have the whiff of real world about them.

    There are a few things about the subject I can say with some real-world authority:

    1. There are plenty of physicians using EMR’s now, with good results (as they define good), and higher productivity than when they were on paper.
    2. The implementation horror stories are almost always from lazy preparation on the part of the administrators.
    3. Some physicians will never use a computer for their clinical record. The most useful thing I got from Thomas Kuhn’s “The Structure of Scientific Revolutions (he gave us the now exhausted term “paradigm shift”) is the dinosaur principle: when a paradigm does shift, the old guard does not learn the new ways. They simply go extinct.
    4. I would wager the average IQ of software engineers is higher than the average IQ of physicians. (And of practice managers.) They do have a disconnect at times, but the medical profession has not earned the right to lecture us about disconnects, I’m sorry.
    5. Neither are hospital administrators evil. Everybody thinks everybody else is evil.

    • Nice to see comments from and relating to non-physician use. Being a nursing informatics professional – I see it as my professional responsibility to ‘bridge the gap’ between clinical practice and IT (evaluation/teaching/data-mining/report writing/workflow analysis). The piece that seems to be missing from a LOT of blog commentary is that (wait for it…) “in my experience” physicians ONLY represent about 25% of active end-users (in a large academic health care setting). The VAST majority of users are nurses. They’re the ones who enter or confirm patient information, document assessments, drug delivery and response, initiation of treatments or labs, and in some cases – manual vital signs/IV pump info. Don’t get me wrong, physicians play a very important role in this production, but as the author points out, just because an MD is on the board of an IT company…don’t assume everything’s “all set” with that EHR. There are many many end-users and standard/custom interfaces of all shapes and sizes for these things. And just like the first-year intern and seasoned physician…listen to your nurses!

  7. John,
    I am thankful that you brought up the “business experience” and associated “cashflows”.

    I think it is preposterous to talk or write about any subject matter (other than politics, of course 🙂 ) if you have no experience in that area. Since most of us have to work for a living, I would argue that the best way to acquire such expertise is to do actual work in that particular area, as opposed to reading and researching on Google.
    For example, I value EHR and health care opinions coming from practicing physicians, who get paid for their work with patients and therefore have obvious financial interest in the matter, much more than I value theoretical “learned” opinions on how things should be done. It is very seldom that solely book-based theory and actual practice are compatible with no modification.

    On the other hand, we can assume that cashflows are the overriding consideration for any and all opinions, in which case the only valid suggestions should come from those who have very little understanding of anything in particular.

    It is pretty scary to me to watch folks that have never spent one day seeing patients, designing software, deploying IT, adjudicating claims and dealing with the myriad of everyday problems associated, demand some sort of holier than thou, authoritative and exclusive rights to analyze and theoretically fix health care and health care IT. Furthermore, if you want to follow the cashflows, you will always find some supposedly self-serving reason for everything ever said and done.

    On a personal note, do I financially benefit from the existence of HIT? Yes. Do I financially benefit from a particular “flavor” of HIT? No. Do I benefit from physicians rushing headlong into an EHR disaster? No, and even if I could benefit, I would choose not to. Because there are all sorts of other considerations driving one’s actions and those driven solely or mostly by cashflow considerations are either in jail or flying a private jet. I am neither.

    • “I think it is preposterous to talk or write about any subject matter … if you have no experience in that area… I would argue that the best way to acquire such expertise is to do actual work in that particular area”

      But, as the physician editors and authors at sciencebasedmedicine.org are fond of pointing out, “the three most dangerous words in medicine are ‘in my experience’.”

      I am not a physician. Does that axiomatically nullify my (reflexively guarded, btw) views with respect to HIT?

      • It nullifies your (professional) opinions on how to treat disease, although now that everybody is on Google, everybody is a “doctor” 🙂
        Who needs experience when you have the world at your fingertips. It takes all of 5 minutes to copy and paste something from Wikipedia, or some random article.

        • I never, ever proffer opinions on how to diagnose and treat patients. Moreover, in our work, we are scrupulous to always advise our clients that THEY are truly the experts, both with respect to clinical assessments and their own processes. And, that is Toussaint 101, not some random University of Google stuff pasted out of Wikipedia.

  8. I was really enjoying this blog entry, and bought into it a lot more than I usually do Ms. Gur-Alie’s arguments. Not until the end did I learn that she has business experience in this area. I wonder if the cashlows from HITECH and the Medicare incentives will be enough to “tip” EHRs into the mainstream. I suspect that these cashflows will not overcome the obstacles described in this articles and elsewhere.

  9. Great piece, Margalit. Of course EMRs are not perfect, anymore that anything else in the messy real world of doctors and patients is perfect. Those complaining loudest and categorically about EMRs are not complaining about EMRs – they are complaining about accountability, job dissatisfaction, and the loss of what they had hoped would be unlimited and unquestioned professional power. Classic “displacement” theory.

    • “what they had hoped would be unlimited and unquestioned professional power. Classic “displacement” theory.”

      Ding, dig, ding, we have a winner. LOL.

  10. Exactly, Bobby.
    For example, the “incorporate structured lab results” criterion, does not actually require ability to receive HL7 formatted lab results, so, according to NIST, one could certify with some text file input of their own choice and design. I can guarantee that no lab facility will comply with whatever fictional file was used for “certification”. So what exactly does that “certify”?
    If I was a betting person, I would bet that one of the “usability” criteria to come out of NIST will be font size no smaller than some arbitrarily set number. Very useful indeed…. and very “easy” to check on every single screen…

  11. Here is the deal with Usability: It is very hard to define and based on CCHIT’s usability evaluation, which is already incorporated in comprehensive CCHIT certification, there isn’t much value associated with such testing.

    That is not to say that standard usability guidelines should not be available, and they already are, but applying those to software (any software) is not as straightforward as it sounds and it will not solve Steve’s problems associated with data entry and interoperability.

    As Dr. Levin wrote on another thread, I am also disappointed with the NIST certification criteria, which allowed an inordinate number of software packages to certify, particularly for ambulatory practice, with minimum functionality and even less utility. I suspect many of those will not be able to allow their proud customers to reach Meaningful Use.
    I see no reason for NIST to be more successful in tackling the much more complex issue of usability. Besides, not everything has to be run and decided by Government. I think customers and the market should be allowed some input into what is built and used. What looks usable to some, may look dreadful to others, and I think folks like to have choices.

    If the government wishes to dictate user interface design through usability certification criteria, and database design through the metadata tagged elements requirement, and vocabulary through the UEL, and control over exchange through DEAS, and functionality through Meaningful Use, then how about the Government just builds an EHR and gives it out to everybody for free, or mandates that everybody buys the same one?
    Why waste time and money on so many HIT companies trying to compete and invent a better product?

    • As I wrote on my blog, ONC’s NIST MU certification testing is simply “User Acceptance Testing.” It merely addresses whether an EHR or module can can capture one of more MU criteria. There are, as of last Friday, 523 certified products, 363 outpatient, 160 inpatient. It has ZERO to do with “usability” per se.

      There is no information on who applied and failed.

      Looks like Everybody Gets A Prize.

  12. From the just-released ONC “Health Information Technology Strategic Plan 2011 – 2015″ (which is now in public review and comment period, ’til April 22):

    ‘Strategy I.A.9: Encourage and facilitate improved usability of EHR technology. The government is collaborating with industry and researchers to improve the usability of EHRs. The usability of EHRs is considered a key barrier to meaningful use and adoption. NIST is developing a set of objective and standardized criteria (standards and test methods) that can be used to evaluate and improve the usability of health IT systems. NIST has released a Common Industry Format (CIF), a standard for developers to report usability test findings and demonstrate evidence of usability in their products in a format that allows for independent evaluation of a single product and comparison across multiple products. NIST is developing guidance and tools for RECs and professional societies on available tools and resources to incorporate concepts of usability in selecting and implementing EHR systems. AHRQ is developing toolkits that medical practices can use to assess the usability of EHR systems and assess the redesign workflow. In addition, AHRQ conducted research and convened industry workgroups that provide perspectives on what constitutes usability and how to systematically improve the usability of EHRs.

    ONC has directed one of its four Strategic Health IT Advanced Research Projects (SHARP) (see Strategy V.B.2) to further EHR usability through better cognitive and user-centered design. In addition, ONC is working with private sector groups to encourage the collection of usability information and its dissemination to vendors and consumers through mechanisms they can trust. [pp 13 -14]”

    I addressed some of this “usability” stuff back in my Feb 27th post (and elsewhere):


  13. I can’t wait to get an EHR, that works. I long for the day when we have universal health care and working EHRs. It would be heavenly to not have to guess at the medical history of so many of the patients who show up in my OR. But, we are so far away from this. All of the EHRs I look at for hospital care suck. We are even further away from universal care. Thus, if my patient had a stress test or echo a week ago at a competitor hospital, I cannot obtain the results much of the time. It can take hours to obtain the information. Meanwhile, my trauma patient or even my regularly scheduled patient waits, with Or time burning away.

    I can wait for the universal part, but please, get us something that works. If it takes me more time to input data into my EHR than it does to do a case, it is useless. While you are at it,, make it so that they are integrated with a medical database so that when I order meds I can quickly double check dosing or interactions if I need to do so.


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