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10/18/2013
05:24 PM
David F Carr
David F Carr
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Why Doctors Hate EHR Software

Have meaningful use incentives merely propelled sales for a lot of lousy software?

9 Mobile EHRs Fight For Doctors' Attention
9 Mobile EHRs Fight For Doctors' Attention
(click image for larger view and for slideshow)
Maybe this will be a "no duh" observation for those who work in healthcare or health IT, but a lot of doctors really hate the electronic health records (EHR) software they're compelled to use.

As an InformationWeek staffer recently assigned to this beat after only occasionally covering health IT in the past, I was surprised how unanimously and passionately dissatisfied most doctors are with the usability of this software, which they see as draining rather than enhancing their productivity. I'm sure there are exceptions where doctors are more enthusiastic about technology, the software they are using is higher quality, or a little of both. But if you open the door to a conversation about how horrible medical records software is, you'll get an earful.

Here's what I'm basing this on. Having spent the past few months writing about massive open online courses (MOOCs) for the education beat, I was happy to discover a Coursera course on Health Informatics in the Cloud starting at just about the time that I needed to come up to speed on my new beat. I'm happy to say the instructor, Georgia Tech's Mark L. Braunstein, MD, will be contributing to InformationWeek as a columnist, so watch for that. Braunstein has spent most of his career in healthcare IT, so I think it's fair to say he's a true believer in the potential and the necessity of digitizing medical information. However, when I turned to the course discussion forums I found a message thread titled "Health IT Doesn't Fix Problems -- Good Health IT Does."

[ Case in point: In One ER, EHR Takes 44% Of Doctors' Time. ]

One of my classmates was a pediatrician named Dave Denton, and the point of his discussion was that he hadn't seen a heck of a lot of good health IT.

"I use several EHRs in my clinic and hospital," wrote Denton, who practices in Portneuf, Idaho. "None of them allow transmission of data between systems. They all are encumbered by poor graphic user interfaces that make it hard to see patient data in a way that makes sense and helps patient care. It is actually much harder to take care of sick patients in the ICU with our new hospital system. They also tend to hide the pertinent by scattering it through the program and displaying all types of ancillary data, time stamps, and formatted notes that are inserted to ensure appropriate coding, but get in the way of seeing what is important. I have made several errors by failing to find the correct information in the chart because it was buried in the note. Finding what is important has become a treasure hunt."

In a follow-up post on dysfunctional workflow imposed by the software, he added, "I am not one of the physicians striving to resist change and implementation of EHR. There are so many valuable things this technology can bring to medicine. I am the chairman of our information systems committee in our hospital striving to make things work, but frustrated by the poor quality of products that have been forced into the marked by unrealistic timelines."

In his posts and in an interview where he elaborated on the same themes, he made it clear that he sees the potential for health IT even though he has so far been disappointed by the reality. At about the same time that I was tuning into Denton's rants in the classroom forum, a similar very active, overwhelmingly negative conversation popped up on the LinkedIn HIMSS group, under the title "Can we turn EHR dissatisfaction around?" (Hat tip to Jennifer Bresnick, an editor at Xtelligent Media, for getting the conversation started.)

The bottom-line answer from most (but not all) of the doctors and healthcare workers chiming in on that discussion was, essentially, no, not going to happen as long as there is such a mismatch between how the software in healthcare works and how the people in healthcare work. Clearly, the government agencies promoting the technology are in thrall to the software vendors, or why would they be pushing this so hard?

Typical lament: "How did IT get more powerful than the people who actually care for patients? The answer is that IT charges by the hour, while Docs can be made to do more work for less money, that is, add 2 hours work to every day without additional compensation. If we asked IT to do the hard work, we'd have to pay them." I don't want to quote by name without permission, but another commenter identified as a medical director for a healthcare group pointed out that any drug or medical device would have to be proven in FDA testing before being adopted into a hospital, while EHR software "impacts quality of care, and expecting to improve it 'on the job' causes delays in care, complications and death. Piece of advice, if anyone of you or your family has to go to a hospital make sure someone stays with the patient because the nurses will be on the computer."

Offline, I'd been hearing something similar from a friend in my Toastmasters group who is an emergency room physician. Practicing for a speech to a professional organization he is active in, he put almost as much emphasis on the productivity drain from electronic recordkeeping (and the coming horrors of ICD-10 expanding the number of codes to remember) as he did on the reimbursement squeeze aspects of Obamacare.

In both of the online conversations I referenced, there were technologists defending the good intentions of IT. They proposed solutions like better object-oriented software to separate generalized features from the requirements of a specific institution, or better use of either voice recognition or human-powered transcription to get the doctors away from doing so much data entry. But even those arguing that good EHR software is possible tended to acknowledge that a lot of EHR software is crummy. I hear the same thing from EHR vendors when they're talking about other people's products.

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Alex Kane Rudansky
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Alex Kane Rudansky,
User Rank: Author
10/21/2013 | 4:10:24 PM
re: Why Doctors Hate EHR Software
While I agree that government intervention has rushed the process and many (if not most) health IT pros are pushing for a Meaningful Use timeline extension, it's important to acknowledge the value of the government's role here. HITECH got the ball rolling. There are problems with the implementation and adoption guidelines, but if not for government intervention, where would the implementation and adoption rates be? Not anywhere near where they are today.
Bob Gill
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Bob Gill,
User Rank: Apprentice
10/21/2013 | 9:53:20 PM
re: Why Doctors Hate EHR Software
USA doctors' opinions are something I've always had issues with - maybe more to my point, Dentists. As the former CIO for one of the first Dentist Office SAAS, I never gave much credit to the dentist.

I've also done medical IT, and doctors are typically more hands-on than dentists, but still not good. Many (most?) USA doctors hate being judged and held to standards. Their egos get in the way of good medicine.

In many hospitals, it's been shown that doctors don't clean their hands between patient visits. When hospitals try to implement surgical check lists, like airplane pilots, to reduce errors and infections, doctors refuse to utilize the lists. In study after study, following procedures with patients and surgeries saves lives and costs, but doctor egos don't care.

The USA needs a common standard for IT health and the data should be available throughout the world via a secure Internet connection. The paperwork is part of the healthcare process. If doctors want a single-payer system for low paperwork requirements, they can push to have one that also just pays them $75k to $150k per year.
David F. Carr
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David F. Carr,
User Rank: Author
10/22/2013 | 2:23:55 AM
re: Why Doctors Hate EHR Software
I'm more troubled by the notion that systems are being rushed into production prematurely. Digitization of health records isn't or shouldn't be the end in itself. The result should be something like quality, productivity, or efficiency. Are we "farther ahead" than we would be otherwise towards those goals? It seems to me those things ought to be achievable, but are these policies really getting us there? Or just putting more stress on an already stressed system?

I have to at least question that.
Loran
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Loran,
User Rank: Apprentice
10/22/2013 | 7:46:51 PM
re: Why Doctors Hate EHR Software
Fellow student in the GT Coursera class - thoroughly enjoying Dr.
Braunstein's explanations and interviews with industry players. I'm not involved enough to have an opinion on EHRs or government stimulation of their proliferation, but I did want to comment on the fact that there are many resources for physicians looking for guidance in setting up and running an EHR. CMS provides extensive documentation in addition to 62 Regional Extension Centers (which claim to provide support to 44% of primary care providers). In addition to that, non-profit organizations (such as the Physicians Foundation) have set up grants to assist physicians in choosing and implementing an EHR. Would be interesting to see a breakdown of dissatisfied physicians - how many of them used available resources, what kind of EHR they are disappointed in, and the main points of contention with the software.
David F. Carr
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David F. Carr,
User Rank: Author
10/22/2013 | 11:02:13 PM
re: Why Doctors Hate EHR Software
This came in by email (I asked permission to repost it here):

OK, the Docs hate their EHRs. I get it, IGm a software
person, IGve been there.

On the other hand. Healthcare was a lagging adopter of
software for years, in fact decades. The physicians werenGt in there
fighting the good fight back in the 70Gs, 80Gs and 90Gs now were they?
Not most of them. So their software, stuff directly related to clinical
practice, is problematic. That can be attributed in part to the lack of
customers and the lack of actionable feedback going back all those decades.

Is there blame to be had in the Independent Software Vendor
(ISV) community? Sure. However here in the real world of software,
the one where I live, the software is often issued in a poor state. Then
the battle begins to improve it.

And thatGs the issue. Engagement. ItGs the
thing that has been largely missing all those decades that were lost. So
all those doctors bitching online, do they engage with the vendor? Are
they submitting bug reports and enhancement requests? Or are they just
complaining about the problems online and to any sympathetic ear they can find?

ThereGs another thing too. Your article suggests repeatedly that the government is to blame for all this. ThatGs funny, I donGt remember the government publishing any EHR/EMR software! That stuff is private sector last time I checked.

The only thing the government did was to create financial
and regulatory programs and policies. OK, they are goosing the market but
it was a market sorely in need of goosing. Left to themselves the
physician adoption rates of EMR software were pathetic.

Remember the Enterprise Resource Planning (ERP) wars of the
late 1990Gs? Lots of ERP customers grumbled about cost, usability, vendor
lock-in, over-long implementation cycles and all the rest too. You can
say the same thing about databases, financial systems, operating systems, on and
on it goes.

Our physicians like to present themselves as a totally
unique profession, not comparable to anything or anyone else. Well IGve
worked both inside and outside of medicine. Take it from me, medicine has
far more factors in common with other industrial sectors, than factors
completely unique. The physicians are going to have to fight for better
software just like the rest of us.

That process is called capitalism. The really
incompetent products and vendors will eventually die away and better ones will
thrive. What if the physicians do not engage? Then their concerns
will be under-represented and things will not change. That sounds an
awful lot like medicineGs past and not a prescription for the future.

Regards,

Brian Harder
Senior Programmer Analyst
Alberta Health Services
David F. Carr
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David F. Carr,
User Rank: Author
10/22/2013 | 11:08:52 PM
re: Why Doctors Hate EHR Software
A more scientific poll would be good, I agree. So would an objective usability analysis of EHR software to separate the grousing from the real complaints.
Loran
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Loran,
User Rank: Apprentice
10/23/2013 | 2:20:30 PM
re: Why Doctors Hate EHR Software
I find readmissions and chronic illnesses being blamed on patients' lack of engagement/adherence to be cruelly ironic in light of your comments, with which I mostly agree. I would add that the fight for better software is not the physicians' alone, but that somewhere in an iterative feedback loop the patient's voice needs to be heard as well. Too bad we're all too busy dealing with sticker shock and the subsequent billing/insurance departments to give our proverbial two cents about how well the software is serving us.
Lawrence Harris
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Lawrence Harris,
User Rank: Apprentice
10/23/2013 | 10:38:27 PM
re: Why Doctors Hate EHR Software
Like most here I basically agree with the sentiment. I have worked in healthcare IT for 30 years and one thing that is a common thread is it's been hard getting the doctors to engage. It's really easy to grab a paper chart, make some hand written notes and pass it back to the nurse or clerk for filing. Now meaningful use says all this must be recorded electronically and that takes time and effort that was not required before. Voice recognition or handwriting recognition is not good enough so they must type it in or proof read it. If the EHR data entry is unstructured then the data is hard to share, if it structured then it can be even more time consuming to enter it and frustrating if something has not been accounted for.. I don't think there is a winning solution yet. I do believe though that in time the patient will benefit.

If meaningful use has one big flaw right now it is too concerned with what data gets collected rather than the communications of data for sharing amongst healthcare professionals. For example an optometrist must collect data about smoking and weight and communicable diseases amongst other items when all they want to do is sell a prescription and a pair of glasses. This leads to software that must try to incorporate facilities that have no direct benefit to the doctor or the patient except that without them the software can't be certified and without using them the doctor then can't get his credits for using an EHR.

If there was more focus on building concise data sets relevant to each area of specialty and the standardization of reporting content via the CCD so that content could be electronically imported and exported we could be further ahead without aggravating the doctors quite so much.
anon4562395785
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anon4562395785,
User Rank: Apprentice
10/23/2013 | 11:03:33 PM
re: Why Doctors Hate EHR Software
Your observations are likely just the beginning. Check out the #EHRbacklash tag on Twitter or this post I did about the coming EHR Physician Revolt: http://www.emrandhipaa.com/emr...

There's definitely a lot of dissatisfaction and things like MU just make it worse.
4thDimension
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4thDimension,
User Rank: Apprentice
10/24/2013 | 3:22:48 PM
re: Why Doctors Hate EHR Software
Meaningful engagement by physicians is indeed a huge problem. I work in an institution on an EHR implementation and mainenance team which consistently sees many MDs refusing to attend training and making ridiculous demands on how our small team should teach their larger collective team while continuing to fix "problems in the system" for them which often amount to not knowing how to use the system because they have refused to get training! And why is it there are so many "research" papers on physician opinions and a complete paucity of opinion by any other health-care provider? The same issue has reared its head numerous times in the past several decades with physician groups such as the AMA writing scope of practice papers on what other health-care providers can and can't do while their group consistently pushes the very work they are complaining is being stolen by other professions in a manner which is "outside their scope of practice" on those said other providers by pysicians because they don't want to do the work. (I am also a practicing Pharmacist.)
Double-speak among MDs is common. Many meetings we have contain both the satements "the system didn't tell me I should..." or "the system didn't warn me about..." along with "I'm alert fatigued". You can't have it both ways! It is also not uncommon to have a discussion where "alert fatigue" is first cited followed not more than 5 minutes later by "can't the system give us warning about that?" Really!?!

I can't in good conscience let the government regulations or insurance companies off the hook though either. As mentioned in the article briefly, regulations on how to submit data, what the data has to say, all the wierd hoops you have to jump through to get a claim processed and even more importantly what boxes to check so it doesn't get denied are ludicrous at this point. There is definitely pressure from these stringent and often not well planned out requrements which make EHR endeavors that much more complicated.
Let's be really honest here, not all this software is that crummy. Many products are quite useful and can be tailored to meet the needs of providers of all types with proper engagement. An iterative, agile methodolgy needs to be used in order to get the best results.
Finally, let's once again look at some of these complaints in a truer light. I have looked at medical records from my personal experience as well as my family member's experiences in both the paper and electronic world. The mistakes made in physician documentation are unchanged in this small sample between both environments--statements of complaint which were not discussed inserted, wrong medication names (and I'm talking on the lines of Zantac versus Pepcid here which could never be a system suggestion error) and the list goes on. Also, we have not noticed a difference in wait times at the clinic to see the doctor or actual amount of time spent with a physician between the paper world of yore and the electronic world of today. These differences from a patient's perspective are far more important than the number of clicks to complete a note!
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