EHRs Are Workarounds, Rerouting the Way Physicians Work


IT GUY: Hey, Doc, don’t make up workarounds, use the EHR the way it was designed.

DOCTOR: Listen, your whole EHR is a workaround itself – around the way medicine is practiced.

– Hans Duvefelt, MD

This was a tweet I posted a while ago. I expected it to either go viral among doctors or catch the ire of administrators and IT folks. Neither happened. So I’m back on my soap box:

Imagine creating a computer simulation or video game that people expected to prepare them for or refine their skills in any given sport. Then, assume that this game altered the rules of the game – using a volley ball instead of a hockey puck, scoring goal attempts rather than goals, rewarding slowness rather than speed and so on.

Then, imagine you, the programmers/code writers, went to the team owners and proposed athletes and coaches should abandon the time-honored rules of the game and instead play like it plays out on the pixelated imitation you just created. And just to be clear: You, the programmer, actually never played the game yourself.

You’d get shown the door and sent back to the digital drawing board.

But that’s not what is happening in medicine.

FIRST: Is finding the clinically relevant information easier than, or at least as easy as, the regulatory information? (The cumbersome ways we have to enter information is a big topic, better covered separately.)

Here’s a silly example: One of the EMRs I work with displays prominently that the smoking assessment requirement has been satisfied, but I’ll be darned if I can see whether the patient smokes or not. Whom does the Holy Grail serve here?

SECOND: Why is it that EHR interfaces are so far removed from how doctors think?

Show me a lab result and imagine what I would need:

– The prior value?

– The current medications?

– The current vital signs?

– A quick way to order medications?

– The patient’s next scheduled appointment?

– A quick way to make sure the patient gets a followup?

– The patient’s phone number?

– A quick way, on the same screen, to order more labs?

– And more…

Any EHR can do these things, but our gripe is that many interfaces are rudimentary and require countless clicks. Then, when you get to the next screen to do what you needed to do, you can’t see the screen that prompted your action, and so on.

I also object to how my (Greenway) EMR doesn’t understand that when I prescribe a medication, I am doing it righ now (it asks me what date I’m doing it) and what type of “encounter” this is (a “medication” encounter, what else?).

More Greenway gripes: A patient is on losartan. I decide to stop it. I click “discontinue”. While doctor-think is that the medication list at the beginning of the visit note includes the losartan and the PLAN includes an AUTOMATIC notation that I stopped that particular drug. (After all, the patient had that particular drug in his bloodstream after already taking their morning dose). There is also an automatic notification to the pharmacy to stop the (often automatic) refills of the drug.

BUT, in Greenway’s INTERGY, if I just stop the drug, it disappears from the top of the visit as if they weren’t on it when they walked through the door. And there is no automatic comment below that this drug was stopped. So, my workaround, and common doctor logic, is to stop the drug TOMORROW. (I then have to MANUALLY type “STOP LOSARTAN”.) I mean this is what the patient will actually do, right? But when I choose a future date do stop the drug, the system claims to be unable to notify the pharmacy. So I then have to pick up the phone and let them know.

The programmer in this case obviously has NO IDEA how doctors, patients and pharmacists think.

Imagine if you had $1,500 in the bank and took out $1,000 today, and your statement showed only that you had $500 without mentioning that here was a transaction at all today. Wouldn’t that seem confusing?

So, don’t be too hard on me for using workarounds. I’m just trying to do my job with tools made for some other occupation than being a doctor.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.