Tech

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So today I’m doing anesthesia for colonoscopies and upper GI scopes. Nowadays we have three board-certified anesthesiologists doing anesthesia for GI procedures every single day at my institution. I’ll probably do 8 cases today. I will sign into a computer or electronically sign something 32 times. I have to type my user name and password into 3 different systems 24 times. I’m doing essentially the same thing with each case, but each case has to have the same information entered separately. I have to do these things, but my department also pays four full-time masters-level trained nurses to enter patient information and medical histories into the computer system, sometimes transcribed from a different computer system. Ironically, I will also generate about 50 pages of paper, since the computer record has to be printed out. Twice.

No wonder almost everyone I know hates electronic medical records! I don’t know anything about computers, and I don’t know what systems other hospitals have. I may be dreaming of a world that doesn’t exist or that world is here and I haven’t heard about it. Nevertheless, here’s my wish list for a system that doctors would actually want to use:

1. Eliminate the User Names and Passords: You can’t tell me that in this day of retinal scans and hand-held computers that there isn’t a better way to secure data. What if each person had their own iPad that you only have to sign into ONCE a day that automatically signs your charts. If you’re worried about people leaving them sitting around use a retinal scan or fingerprint instant recognition system.

2. Eliminate the Paper: If you’re going to have full-time people entering data for you, why print it out? It’s on the computer for anyone to access.

3. All Data Systems Must Be Compatible: You can’t have patient data entered in one place that doesn’t automatically import into another place. If my anesthesia record can’t talk to the hospital OMR, I have to RE-TYPE everything in, which is completely ridiculous.

4. Everybody Has to Use the Same System: Everybody, state-wide. Right now, electronic records from a nearby hospital are not available at my hospital, even though the two hospitals are right across the street from each other.

5. Don’t Make Me Turn the Page All the important information about a patient should be on the first page you open when you look up a patient. I shouldn’t have to click six different tabs. Specific to anesthesia, all the relevant data about the patient including what medications they have received during the case should be automatically displayed on the screen when you start a case. Specific to primary care, all the latest labs and data, recent appointments with specialists, current med list and anything else the doctor wants to see commonly should be right on the first screen.

6. Don’t Make Me Have to Repeat Myself. If I do eight cases the same way, with the same documentation required for each case, I still have to enter that documentation each time. If I’m seeing 20 patients in primary care clinic and the rules require the same documentation for each person, I shouldn’t have to enter that documentation each time.

7. Invest in Development of Really Good Voice Recognition Software: If I’m sitting across from a patient, I want to look at them and talk to them, not talk to them and look at a computer screen. If my mother didn’t make me take typing in high school, I don’t want to have to spend 3 hours after-hours every evening pecking my conversations with my patients into a computer, or worse, checking boxes electronically.

8. Get Rid of the Wires: In this day of wireless, why am I still tripping over monitoring wires and untangling cords? My spin bike at the gym can pick up my heart rate without a wire. Why can’t my anesthesia monitor?

9. If You Need a Typist, Hire a Typist: Every time a new rule or documentation requirement pops up, which in my institution is daily, it is always laid on the nurses to add that to their computer records. Nurses used to be nurses. Now they are data-entry specialists. Their checklist and pre-operative paperwork is longer than mine. And they aren’t doing any diagnosis or treatment.

10. Triple Back Up the System: Computers crash. Paper doesn’t. There’s got to be a way to make the system rock-solid reliable.

Shirie Leng, MD is a practicing anesthesiologist at Beth Israel Deaconess Medical Center in Boston. She blogs regularly at medicine for real, where this post originally appeared.

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  62. Great points regarding the usability of current EHR systems and other health IT.

    For some — e.g., putting all hospitals on the same tech platform — no single company can solve the issue. Need everybody to agree on what to do & work together.

    For others — e.g., don’t make me repeat myself — health IT vendors should be doing this already! It’s surprising and unfortunate that many (most?) don’t.

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  64. Dr. Leng,

    Your post inspired my recent one “How Programmers Think: A Doctor’s Guide to Building a Better EMR”. Doctors have failed to realize that they are the customers of these information systems, and they need to state design specifications like you did here.

  65. Preach! Love your list!

    We need more people who actually input data and work with the patients designing these programs- shout out to Nursing Informatics

  66. It should be remembered:

    The role of health IT personnel and physicians is anything but symmetric. IT personnel have no clinical obligations or liabilities. They are facilitators of healthcare, and their role would not exist without physicians and other clinicians, who up to now have been solely liable for outcomes. The opposite is not true – physicians don’t need IT to treat patients.

    However, since some IT personnel seem to act as if they have similar obligations and liabilities as physicians and other clinicians, I am recommending to the Plaintiff’s attorneys I educate on HIT-related medical error that the IT guys be deposed and, where appropriate, named as defendants.

    Welcome to the clinicians’ world.

  67. Oh, where to begin….

    In the first place (although this is changing), many/most docs are not employees of the hospital. They have privileges at the hospital but are not on the payroll. So when a hospital picks an EHR that makes life difficult, it is creating work for people who aren’t hospital employees.

    Your post also assumes that: we need EHRs, they perform some useful service for patient care and docs who didn’t adopt their own are negligent. or behind the times. All of those points are questionable.

    Your last point actually has validity. People like you should be involved in the routine aspects of medical exams. However, I am going to guess that you are; young, relatively healthy, tech savy and literate in English. This description does not fit all patients. I could not see either of my parents taking their weight using an iPhone or using a computer to enter data for a review of systems.

  68. I call this entry pure BS!!!!!! I am so sick and tired of doctors complaining about technology and how bad it is. It is bad. It is awful. But guess what, it was just as bad or even non existent for the solo docs or practice owner docs. They could have bought or built anything they wanted. They did not. Now you are an employee, so suck it up. You decided to give control to your profession to business guys. What did you think was going to happen? You are now a human resource, a healthcare provider just like the check in lady at the front desk. They bought whatever they thought made their jobs safe so now, If they tell you to type, just do it and suck it up.

    Also, I am so sick and tired at being treated like a 2 year old at the doctors office and I am sick and tired at paying for the army of people that supposedly takes care of me. I do not need to have my weight taken and recorded by any one OK? A machine linked to my iphone can do that. The same for blood pressure. The same for all the Review of System crap you ask me every time. I can enter it myself in the computer so I do not have to pay you to do it. Every time I speak to “healthcare providers” about shifting some of the work to the patient (like entering medical history, family history, symptoms etc) I get the “patients are too stupid speech”. Then shut up and type and collect your paycheck every 2 weeks.

  69. Shirie, I read your post and instantly thought you have the beginnings of an AHRQ grant. The AHRQ has a special emphasis notice for health IT.

    For Benoit and Michael, the federal government has already developed and released an open source EMR system for the VA called VistA.

  70. Great piece! There are solutions but the problem is partly regulatory and partly cultural.

    On the regulatory side HIPAA is a mess; the only people can easily get medical records are businesses who shouldn’t have access to it. Angry ex-spouses, employers, insurance company’s .. no problem getting medical records. Other doctors, hired by the patient and working with the first doctors, big problem.

    Culturally, the IT departments of clinics are seen as cost centers, adding no value, and the people who work there are rewarded only for keeping the systems up, never for improving them. This does not attract the highest quality people and, for those employees it does attract, it provides incentives for exactly the opposite of what the practice actually needs.

    Finally, many of these EMR systems are run by sharks who want their system to rule all others, so they try to make them as incompatible as possible. The government is working on data compatibility but it’s too slow and too disorganized. Government should create a web-based system for Medicare that’s free, allow anybody else to use it for Medicare and non-Medicare record keeping (or open source it, allowing people to build on it). Stop feeding the sharks, by allowing proprietary systems, and they’ll go away.

  71. This is a great post. I am a software developer and my wife is a doctor in the process of choosing an EHR for her clinic so I’ve been investigating the options lately.

    It is my belief that most problems with EHRs stem from point 3 and 4 (All Data Systems Must Be Compatible, Everybody Has to Use the Same System). Solving this would also solve the multiple login problem, the repeating yourself problem and simplify backups.

    However these issues are pretty much impossible to solve when you adopt EHRs that store records in a proprietary closed source format. There are two main reasons:

    First, the idea that “Everybody Has to Use the Same System”, when the system is proprietary is a huge cost risk and quality risk. Basically you give a monopoly on medical records to a single company. Only their software can fully access and manipulate the records. Once all the records are in their format you have basically no leverage in negotiating price for continued access to the records because converting and migrating records to a new system would mean huge software development and training costs. The EHR companies truly get you by a leash and they don’t have to spend much on improving and fixing the system since their clients are pretty much stuck. When EHR companies sell you a system, its usually in the hope you will be locked in their system for a long time.

    Second, there are people who think that the solution is to predefine and standardize record formats so that companies can provide software based on these formats. As a software guy I can tell you that this is quite impossible, especially across different competing EHR companies.
    You have to understand that most of the innovation and improvements in software come with changes in storage formats. In a typical application, storage architecture can vary across thousands of different aspects depending on how you encapsulate data, design security, design communication, display data or link data together. A storage format in a software being worked on evolves and changes on a daily basis, often in subtle ways that would trip any other company’s software if they tried to read the files or database. Also, stopping the format from changing would mean stopping the software from improving or being fixed.

    On top of that, EHR companies have zero incentives to keep other companies in the loop and help them be compatible. This would simply be helping their competitors.

    There is only one solution to the problem in my opinion and it is to use open source software at least for the core infrastructure.

    Using open source software means that no single company owns the code to build the software that reads the records. Open source contracts basically say that when you sell your software you have to make the code to build it public. A lot of software is open source including the Firefox browser, the core components of the Safari and Chrome browsers, Android smartphones, most of the internet’s infrastructure, most server code and website frameworks. It is the best model when different companies have to cooperate and be compatible with each other. Yet there is little of it in the medical world. I believe it is often because it is not a product that is marketed to hospital. Since no one ‘owns’ this software, providers of variants of it have to compete on price and services and don’t have a budget for marketing. Hospital would have to seek it themselves.

    When a software component is open source, it is easy for new software companies to read, modify and customize the code in order to create compatible competing versions or build modules to complement it. If doctors or patients become dissatisfied with a provider, they can easily switch to another one that offers different services, better prices or even a differently customized version of the software. Since different companies offer almost the same software, they have to compete on price.

    It doesn’t mean all your software has to be open source. You can easily connect it with proprietary add-ons such as dictation software. But even these addons can be better integrated when their maker can read the code of the core software they connect to.

    In Canada, the open source Oscar EHR (http://oscarmcmaster.org/) is gaining popularity. I really hope it catches on.

  72. Just persuade the governments to withdraw all the Privacy Laws and to instate death penalty for Pirates.
    Then buy a very very large monitor.
    Finally call us, we have some solution for you.

  73. Brenda,

    You have hit the nail on the head! You are not serving the patient when you fill out all those forms, you are serving the malpractice attorneys and the payors .

    Filling out all of this nonsense “paperwork”/electronic forms, takes time away from seeing the patient, listening to the patient, examining the patient, etc. – the important part of being a nurse.

    Anecdote – my dad died about a year ago and for the last year of so of his life he was “on hospice” because of a Klatskin tumor. He actually did so well for a while that he got kicked out of hospice. What being “on hospice” consisted of – for him – was having an excellent nurse come around once a week, give him a good bath, give him a good shave and baby him a little. He really liked her and what she did was worth a lot to him. And of course they talked together about a variety of things. They bonded – when I would go see him he would tell me about her and her life.

    While this was going on the RN’s at my Dad’s “assisted living center” were generally busy writing in charts, filling out papers, etc. This is backwards! The RNs should be seeing the patients and the nonsense paper work should either be eliminated or given to clerks.

    Documentation (forced on us by lawyers and insurance companies) is the enemy of good interpersonal care. The kind my Dad so appreciated.

    She wasn’t an RN, she was an LPN or some other type of lower level provider.

  74. The problem with so many electronic record systems is that to share the information, you open up the security every time another party has access. This freaks tech admins out. Any connected db is open to hacking as shown regularly on the news.

  75. As an IT guy, I thought I would come in here and get mad, but after reading these I actually found myself laughing a lot. Nicely written article! The password thing would be number 1 on my list also. Not to mention having to change the password every X number of days and then you can’t use your last X number of passwords, etc. What a bunch of bologna.

  76. I am an IT person and can still cite examples where the corporate IT organization was equipped to do a simple thing to make the care provider’s job easier, yet refused to do so because they did not understand the request. I know IT is difficult and most large IT shops are understaffed and overwhelmed. What I don’t get is the lack of understanding that the sole reason their job exists is to enable the care team to function more efficiently. Patients do not visit a hospital to meet the IT guy. They visit a hospital for care from the providers. If IT is not empowered to deploy solutions that enable the functionality listed above, senior leadership needs to change. If IT is empowered, yet chooses not to, they need to be replaced.

    My company has designed an EMR that addresses most of these issues, but we are often excluded because IT won’t investigate our solutions. The fear of purchasing from a smaller company that can provide innovation, support, and flexibility is greater than the pain they inflict on their providers by deploying archaic systems.

  77. As an RN, let me say THANK YOU for mentioning point #9: “Every time a new rule or documentation requirement pops up … it is always laid on the nurses to add that to their computer records.”

    and

    “Nurses used to be nurses. Now they are data-entry specialists.”

    5 or 10 years ago, my charting to document my patient’s assessment (Med/Surg floor) covered 1 computer screen. Now, it is dozens of screens. Yes, DOZENS. I have to document not just things one would expect like heart sounds, lung sounds, etc, but also items such as:
    -That alarms on all machines connected to the patient are audible
    -That all spiritual and psychosocial needs were addressed
    -That I have done teaching about drug resistant organisms
    -The patient’s risk of falling (5 computer screens for that item alone)
    -Nutrition risk
    -Skin breakdown risk

    …and on and on.

    The burdensome documentation was one reason that I decided to retire early.

    Sad .. I absolutely LOVE being a nurse. But not being a data entry specialist.

  78. Great points. I think, at least on the information governance and sharing side, the answer will be found by putting patients in control of their records through a patient-controlled medical record, rather than trying to kluge together interoperability in HIEs that aren’t really working.

  79. Large vendors = slow to change and last century thinking. The risk is actually higher to stick with the dinosaur technology than to investigate the up and coming businesses that might offer innovation but haven’t yet earned the 10 year track record. Smaller = more flexibility, stronger customer focus, and desire to make it work.

  80. I don’t totally agree. IT is hamstrung by their funding, mindset, and past experiences. Many are averse to change and unable to adjust their perspective from the system to the user. Some companies, including mine, have developed EMR software that adjusts to the needs of the users instead of forcing the user to adjust to the needs of the software. This model exists but is not yet prevalent.

    Don’t let them hide behind HIPAA. That is a smokescreen.

  81. Wow. I never called IT people arrogant and never would. Absolutely our IT guys are working under the constraints of the systems the hospital bought, regulatory factors, and security concerns. I’m really addressing my complaints to the broader EMR community at the coding and development level.

  82. HIPPA is the problem here. Yes the 600 million dollar implementations are a result of government regulation. The new requirements are coming out faster than IT can typically keep up. With people still tweaking 5010, ICD10, down the pipeline, and keeping up with meaningful use, I think everyone is feeling the squeeze here

  83. Right Fricking On, Dr. Leng! Send this email, not to your Tech guys, who are drowning, but to the CEO’s of the software firms that designed your stuff in the first place. Maybe they could get you on the program at the next HIMSS conference, the IT vendorfest where all this stuff is sold.

    Priceless feedback from a frustrated user. You speak for millions.

  84. You sound like one of the tech guys as in the guys or gals in IT. Not sure what that has to do with the tech guys as in the guys or gals who code software. Sure you may have taken lots of code classes and might occasionally even use what you learned to write a batch file or interface, etc., but I doubt you had anything at all to do with the POS software the poor doc is forced to endure. So in other words your hackles are up for nothing.

  85. In response to your under clarity and lack of an IT perspective my dear physician, followed with a response to the “arrogant IT people”. Pot please meet kettle!! You speak of IT as arrogant, but perhaps the answer of “no or it cannot be done” isn’t arrogance at all. See you practice medicine, as you state above. Your phd didnt encompass interfacing, workflow, networking, software and security. Our two worlds have collided, that is a fact. You would scoff at the idea of an IT person treating your patient because they aren’t trained to do so, yet feel the need to belittle or undermind the very services they provide. Perhaps you should give these very same people the ability to critique your work, second guess your decisions, call to light your misdiagnosis’s, you know the ones these very people fix before the judicial system has requested. I presume your IT personal are working within the confines of what is allowed and how the softwares are designed to function. Maybe using their expertise to have continual discussions with your vendors will allow you to refocus on your expertise.

  86. You’re just a Luddite technophobe, Dr. Leng.

    Don’t you know that meaningful use of EHRs automatically and dramatically improves the quality of care, saves billions of dollars, allows medical errors to be eliminated (even, say, perforations during your procedures, as the Lords of Kobol are overlooking you with EHRs), and rejuvenates the patient by at least ten years?

    What’s the matter with you, anyway?

    See my blog writing at http://hcrenewal.blogspot.com for more on the miraculous benefits of EHRs…and stop being such a whistleblower.

    — InformaticsMD

  87. m13 – thanks for reading. Colonoscopies are never done without sedation. Nurses can provide perfectly adequate intravenous sedation for this procedure. What Fan of HIS is talking about is sedation done by anesthesiologists, a much more expensive proposition and usually not necessary.

  88. Oh yes, don’t get me going on THAT subject! I completely agree with you. The ones I do are supposedly “difficult”, ie, old, sick, or more often, fat. As long as insurance pays for us, our department heads will keep staffing GI.

  89. Empathize with your frustrations, and I am a patient! I have two docs on the same floor in a medical facility who cannot share my records!

  90. @Fan of HIS –

    If you think there should be no anesthesia used for colonoscopies, I will recommend you to a few colleagues of mine who would be happy to clean our your colon and stick a giant tube and camera up your *** without any sedation. I’ll let you run the ‘clinical decision support systems’ and I’ll just take IV meds.

  91. Little makes me crazier than the arrogance of tech guys (other than maybe the malpractice and health insurance systems :).

    The whole idea that we, the doctors, are out of date, unwilling to change, and locked in our anachronistic ideas and workflows are the reason why EMR systems aren’t being utilized effectively is ridiculous.

    I have experienced every single one of the issues you describe and it is insane making. There are so many true clinical decisions I am running each day, getting locked in documentation and data processing details often just distracts me from the truly important work and from connecting with my patients. Add volume pressures, concerns about accurate documentation for both reimbursement and legal reasons, and the upcoming importance of documentation from a quality correlation, and the system becomes overwhelming.

    With EMR systems being mandated by the ACA and a few large vendors dominating the space, there is surprisingly little incentive for them to listen to their customers and end users and make the changes that we want. Maybe we should just call Vinod Khosla and have him take over for our technologically incompetent selves now.

  92. First question I have is whether the current best evidence suggests that anesthesia should be given routinely for colonoscopies?

    Maybe what you guys need is clinical descision support.

  93. It’s so great that you posted this. I think user responses are so important, and companies that don’t listen to them are doomed to failure. I can understand though why you don’t send it to your IT guys. Do they have that much control over these things?

  94. Money quote #1:

    “Don’t Make Me Turn the Page All the important information about a patient should be on the first page you open when you look up a patient. I shouldn’t have to click six different tabs.”

    Money quote #2

    “If You Need a Typist, Hire a Typist: Every time a new rule or documentation requirement pops up, which in my institution is daily, it is always laid on the nurses to add that to their computer records. Nurses used to be nurses. Now they are data-entry specialists. Their checklist and pre-operative paperwork is longer than mine. And they aren’t doing any diagnosis or treatment.”

  95. Imagine, if you will, being a patient or caregiver with a number of clinicians in different facilities, using different systems, and you’ll know that your pain isn’t felt only on the clinical side.

    For patients, data contained in our EMR could spell the difference between life and death. What if it’s wrong? And so much of it is wrong, particularly on the med-rec side. We can hardly see it. We cannot in any easy way fix it ourselves.

    For all the promise that EMR tech holds, we’re seeing none of it delivered in the US. $9B is buying us shiny new silos to replace the dusty paper silos, but any meaningful use-fulness is almost accidental.

    How about patients AND clinicians band together, and storm the HIT castle? The glacial pace of usefulness development has to accelerate, or we’re all boned …

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