Healthcare // Electronic Health Records
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2/11/2014
09:06 AM
David F Carr
David F Carr
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Doctors & EHR: Can This Shotgun Marriage Be Saved?

Lots of doctors hate EHR software. What makes the difference for those who are happier with it?

8 Healthcare Startups Catch Fire
8 Healthcare Startups Catch Fire
(Click image for larger view and for slideshow.)

There are many things about healthcare IT that I would like to understand or understand better. One of the most basic revolves around happiness and unhappiness, love and hate.

When I wrote a column on Why Doctors Hate EHR Software, I knew that was a gross oversimplification but hoped it would start a discussion. And it has. Most of the discussion it prompted from vendors was about how their product is different, and I don't doubt that physician satisfaction is different from one software package to the next. Reactions to the software can also be much different from one doctor to the next. Even where doctors hate the software with a true blue-hot passion, they may be working side by side with others who grumble about the software's quirks and cope, and yet others who think it's just fine.

Here are some of my lingering questions. I'm not pretending to make this a formal survey, but I'd like your feedback.

1. Who are the happiest electronic health record users?
Who are the people who accept the software for what it is and get the most value out of it? Is there a specialty or a personality type they have in common?

2. Do doctors just like to complain?
Some people like to complain. Maybe complaining makes them happy. I can think of writers and editors who fall into that category. Do doctors just like to complain? Their job is admittedly stressful, so they don't need software to give them any extra grief. But are they just extraordinarily difficult to make happy about anything?

If so, the software developers who manage to make them happy, even occasionally, deserve an extra pat on the back.

[Would Google + CliffsNotes equal happy doctors? See Can This Search Tool Make Doctors Love EHR?]

3. Do younger doctors have a different experience?
One common assumption is that it's the old, grumpy doctors who are least happy with the software. Is that really true? It reminds me of the meme that says all young people are social-media savvy, which is not necessarily true. Besides, those younger docs who are digital natives may not find EHR software lives up to their expectations.

4. Do nurses and other medical professionals have a more positive experience?
The discussion about EHR usability often revolves around those difficult-to-please physicians. Do nurses and others on the clinical team have the same complaints (or a whole different set of them)?

5. Does choice make a difference? Or the pace of change?
One thing I have heard from several sources is that EHR satisfaction is greater when the doctors felt like it was their choice, propelled by their own requirements at their own pace -- rather than something they were rushed into adopting to meet a government mandate. Agree or disagree?

(Source: ALJAppeal.com)
(Source: ALJAppeal.com)

6. How often do doctors see a real, clinical payoff from tracking patient data in EHR software? In what situations is that most likely to show up?
As part of a profile of Practice Fusion and its users, I heard from Dr. Allan Treadwell, a San Francisco internist who said using the software was additional work but that he saw the benefits when he got automated alerts about potential drug interactions, for example. Those are the sorts of clinical and patient-safety benefits that have been promoted as the point of implementing health IT. How often do they materialize?

7. How often does EHR software slow down the process of delivering care without any real clinical benefit?
One of the tradeoffs of filling out a data-entry form, rather than scribbling notes in a patient's file, is the need to fill in all the required fields and check the required checkmarks. This is sometimes justified as a virtue, in that it improves consistency. But physicians complain they spend too much time recording meaningless data like "condition normal, no change" that they would never have bothered to note in a paper file.

How much of the data tracking that occurs in an EHR is superfluous?

8. Do the benefits of this software show up on the billing and claims side of the equation, or in someplace other than the day-to-day delivery of care?
Many EHRs developed as an outgrowth of billing and claims-processing systems, with the goal of getting more of the required information captured at the point of care. Data captured from EHR systems can also be invaluable for research. Is EHR software paying off for the organization, just not where doctors can see it?

9. What aspect of EHR software most cries out for improvement?
Maybe some products do a little better than others with specific features, but where would you like to see dramatic improvements?

10. How well do the Meaningful Use Stage 2 requirements line up with the greatest needs for improvement?
The next wave of requirements from the federal government places additional demands on both software vendors and healthcare organizations. Will they result in more meaningful, productive use of healthcare IT? I'd like to hear your list of requirements for truly meaningful use.

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David F. Carr oversees InformationWeek's coverage of government and healthcare IT. He previously led coverage of social business and education technologies and continues to contribute in those areas. He is the editor of Social Collaboration for Dummies (Wiley, Oct. 2013) and ... View Full Bio

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ZibdyHealth
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ZibdyHealth,
User Rank: Apprentice
2/12/2014 | 2:38:00 PM
Re: No dumb questions
David Voran,

You hit the nail on the head. We need to involve patient in keeping their records. Care providers will get much better patient participation and hopefully this will improve outcomes. To do this we need to make these software packages very simple. Can our moms or grandma handle these records? Someone working in retail without any real knowledge of healthcare, can they manage it. It has been done for other industries and we are trying to do just that with our platform.

Another thing you mentioned, we need to separate out patient care from billing. We get it that billing is critical but so it patient care. One can't have two competing interests without compromising somewhere. Current commercial systems are build for billing. There is a spearate debate if providers need all the explanations to get paid for their work. You are correct with your assumptions why dentist like their EDRs.
Mark Braunstein
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Mark Braunstein,
User Rank: Moderator
2/12/2014 | 11:47:02 AM
Re: All EHRs Aren't Created Equal
David,

I completely agree and was remiss in not making that point in my earlier comment.

Mark
David F. Carr
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David F. Carr,
User Rank: Author
2/12/2014 | 10:36:22 AM
Re: All EHRs Aren't Created Equal
In sympathy with the software developer, we should also acknowledge that it's a tough challente to create a system that is easy yet sophisticated, addressing a complicated scientific discipline while serving other masters like regulators and insurance companies.
David F. Carr
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David F. Carr,
User Rank: Author
2/12/2014 | 10:32:32 AM
Are scribes the answer?
UsabilityPeople
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UsabilityPeople,
User Rank: Apprentice
2/11/2014 | 10:33:35 PM
Re: All EHRs Aren't Created Equal
It is so true that there are a number of EHRs out there with significant usability problems.

We are on a quest to change that, and so should be everyone else.  The ONC Meaningful Use Stage 2 certification requires that EHR vendors conduct and report on a summative usability test of their EHR (using a number of pre-defined typical tasks). That's a start.


Based upon the experiences that we have had working with a number of EHR vendors, we can say that there is a HUGE difference in the amount of time and effort that vendors put into adopting the "User-centered Design" philosophy that is required for the 2014 Certification from an ONC- ATCB.  They need to think ISO 9241-11: Efficient, Effective and Satisfying.


Healthcare IT (much like Enterpise IT was years ago) needs to focus more on the users, their tasks and their workflow.  The days of "Enginering-centric" design are over.  The innmates are NOT running the asylum anymore.

We run a blog site to keep up on Healthcare Usability issues, and often present about usability at Healthcare and UX conferences -- Hopefully we can help you help your users!
DavidV992
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DavidV992,
User Rank: Apprentice
2/11/2014 | 9:53:01 PM
Re: No dumb questions
Can you read "Tiranny of the note?"

The reason Dentists and some other EHR systems (veterinarians comes to mind) are satisfied with their systems is they don't have to document the "leaves" in detail in order to get reimbursed.  As a result the signal to noise ratio is huge compared to most physicians who have sold their souls and now have to grind out excruciatingly detailed notes in order to get fairly reimbursed.

I'm sure if the dentists and vets had to record the same type of notes we physicians have to document there would be no penetration of EHR-like products in their offices.

Either change the reimbursement mechanism or change the rules around documentation and reimbursement so we can stop documenting notes and concentrate on improving the accuracy and integrity of the important parts of the patient's issues.

We also need to change the rules as to who can document what.  Forcing a physician to do everything doesn't provide any of the participatory process that used to exist in paper.  EHR's have taken away a paper based clinic's freedom to leverage the wetware of the employees as with a digital system audit trails can show who's putting in what.

Having said all of this it's still not hard to make things work.  I've been successful in eliminating a lot of noise by incorporating photographs within a large portion of my medical records.  Trouble is photographs are not part of the CCD or similar protocols that are the base for HIE's.  So some downstream readers see a very sparse note.  Fortunately our coders tick off the credits for complete exams when photos are part of the examination.

The more attention we can divert from clinical notes to improving the accuracy of the problem list, all of the past procedures and any of the JHCAHO 5 elements the more valuable the EHR becomes.  The more time and attention is spent on the clinical note the less valuable the EHR becomes.

Finally getting the patient to help with the documentation is a clear winner. Not only do they wind up telling a better story but they get involved in improving the accuracy of the documentation.  We've remodeled our clinics around this so the patients and physcians can work in parallel in a way we could never do in a paper world.  Documented this a long time ago in a blog http://vorand1125.wordpress.com

David Voran, MD
DarrellP725
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DarrellP725,
User Rank: Moderator
2/11/2014 | 6:02:10 PM
Re: Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
Dear David F. Carr,

I was curious if there had been any responses to my comment about electronic dental records when I noticed that I failed to offer a balanced report. As I said, public mention of electronic dental records in the dental community is suspiciously rare. Nevertheless, I have located two independent articles which both assure dentists that they can expect substantial savings from EDRs over paper records. What's more, the long-awaited claims were published by two of the most respected and revered dental authorities in the nation: Dr. Gordon Christiansen's Clinicians Report and the American Dental Association. These are the experts dentists, as well as lawmakers, turn to for advice.

In an undated DentistryIQ article touting the benefits of new technology, Dr. Paul Child, CEO of Clinicians Report says EDRs offer dentists a "high return on investment." (See: "Digital dentistry: Is this the future of Dentistry?" by Paul L. Child Jr., DMD, CDT, CEO CR Foundation).

http://www.dentaleconomics.com/articles/print/volume-101/issue-10/features/digital-dentistry-is-this-the-future-of-dentistry.html  

But unlike the Medical Economics survey you mentioned, in which "almost two-thirds of respondents (65%) indicated that their EHR system was responsible financial losses," Dr. Child offers no evidence supporting his savings claim. The absence is particularly surprising since the Clinicians Report is a research foundation which investigates the cost and benefits of new dental technology... including digital.

Elsewhere, on December 6, the ADA News posted an article titled, "EHRs provide long-term savings, convenience" (no byline).

http://www.ada.org/news/9435.aspx   

Once again, there is no evidence offered supporting the savings claim. However, it is worth noting that the anonymous author points out that The Dental Record is "the only ADA Business Resources-endorsed EHR provider." Later in the same article, she adds, "ADA Business Resources has chosen PBHS Inc. as its endorsed website design and practice marketing firm" - with similar sincerity.

Nobody wants to think about dentists until they cannot put it off any longer.

D. Kellus Pruitt DDS
Mark Braunstein
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Mark Braunstein,
User Rank: Moderator
2/11/2014 | 4:36:09 PM
All EHRs Aren't Created Equal
As some of you know, I teach about HIT and try to do it from a real world perspective so this is something I've though about quite a bit.  (I'm also a "reformed" vendor.)

Frankly, I don't see the added value in surveys like this one.  The result should be obvious pre-survey, given where we are.  There are literally hundreds of EHRs and, from what I've been able to see (I've hardly seen them all), most aren't very good with respect to some key usabiliity issues.

Reader beware: Some of what follows may be a bit redundant with what David and others have already said:

1) They don't integrate well with workflow.  Rather than becoming a seamless component of seeing patients and documenting their care and one that actually improves productivity they are essentially an off-to-the side-extra activity that physicians resent for taking up too much of their valuable time.  This is partially do to poor EHR design and partially due to poor implementation.  In my  years as an HIT vendor it was rare for new clients to take the time to look at their manual processes and think through specifically how they wanted automation to improve them.  I would argue that only once that's been done is a healthcare organization (or any organization for that matter) ready to look at systems of any kind.  It is unfortunately at least equally rare that systems are designed around process.  Far too many EHRs are designed to mimic the paper world (so that sales people can tout how easy they are to use and how little training is involved in learning to use them) rather than provide a tool to improve and optimize office processes.  I won't name names but there ARE exceptions to this out there and physicians should be looking for them.

2) The vendors haven't thought creatively about data collection.  In the end most physicians are complaining that its taking too much time and/or its too hard to enter data.  Of course, in many cases, this is a false comparison between poor, inadequate documentation and forced, more complete documentation but that doesn't change the fact that there are creative EHR solutions out there with respect to data entry (again, I won't name names) and that, from what I can see, physicians really do like those systems.  Caveat emptor.

3) This one doesn't get nearly enough attention.  Once EHRs have the data they typically don't do much creatively to present it back to the physician in ways that both save time and help provide better patient care.   Here I really haven't seen an exceptional EHR and it is something serious vendors should be spending more time on.  The inception of EHR app platforms may offer real help to the extent that their APIs allow indendent developers explore creative approaches to visualization of the underlying clinical data.

BTW, many vendors will point to the high degree of user configurability as the "solution" to #2 and maybe even #3.  Let's get real. Very few end users have the talent or the time to do system configuration well.   The answer is better thought out system design and LESS user configurability -- just ask Apple!

Finally, wouldn't it nice if physicians -- who now are and forever will be essentially required to use EHRs -- were actually trained in health informatics?  I guess its easier for me to be critical since Georgia Tech doesn't have a medical school but I think the time is long past that we keep producing physicians, nurses and other health professionals whose only experience in health IT is learning to use whatever system the teaching hospital they trained in happened to have.  BTW, my hidden agenda here is smarter, more informed and more critical potential customers.  That's the one sure way to get the vendors to improve!
DarrellP725
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DarrellP725,
User Rank: Moderator
2/11/2014 | 1:44:29 PM
Since dentists are not complaining about EDRs, they must be almost 100% satisfied. Right?
What aspect of EHR software most cries out for improvement? Electronic dental records - but the cries aren't being heard.

It seems obvious to me that far too many in the dental profession bought into EDRs far too soon, and now even the highest leaders in the profession refuse to acknowledge that EDRs are both more expensive and more dangerous than paper dental records.

Unlike physicians, very few in the dental community are complaining. It's quiet... Too quiet.

D. Kellus Pruitt DDS

 
David F. Carr
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David F. Carr,
User Rank: Author
2/11/2014 | 1:23:45 PM
Re: No dumb questions
These surveys keep coming

70% of Providers Dissatisfied With EHR Systems, Survey Finds - iHealthBeat http://www.ihealthbeat.org/articles/2014/2/11/70-of-providers-dissatisfied-with-ehr-systems-survey-finds
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