Healthcare // Electronic Health Records
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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?

So far, the only doctors I've heard say nice things about their EHRs have been hand-picked references of the software vendors. (Again, I'm relatively new on the beat, so there's time for that to change.)

It would be easy to shrug off a lot of the complaints from doctors and nurses as the same old change management story, where people complain about whatever they are unfamiliar with. Healthcare providers aren't the first workforce to complain about the shift from paper to computers and being asked to change their work habits to match workflow dictated by software. The logistics workers who complained about the advent of supply-chain automation have either adapted or found another line of work by now, and, once the bugs were worked out, the efficiencies delivered by the automation became impossible to argue with. Eventually, EHR may deliver on all its promises of efficiency and patient safety. But has it been a mistake to rush it?

Obama partisans might also be tempted to see an anti-Obama agenda in this criticism, since this is another element of his healthcare reforms, along with the changes in health insurance regulation. But the sentiment is too unanimous to be that alone.

On the phone, Denton reiterated that he sees "a huge potential for benefit" from health IT. The problem: "Some of it was pushed before it was ready for primetime because of meaningful use."

That is, before the federal government introduced its system of immediate incentives for EHR implementation, combined with eventual penalties for lack of use, his hospital was beginning to introduce the technology, but slowly. "It was happening slowly because the products weren't very usable," he added. The HITECH Act establishing the meaningful use goals was signed into law in 2009 as part of economic stimulus measures, although it can be seen as a companion to the Affordable Care Act healthcare reforms that followed in 2010. Suddenly, EHR implementation became something that had to move forward at a steady clip, whether the software was usable or not, he said.

If not for government intervention, the technology would have been phased in more slowly and carefully, with time for course corrections along the way, he believes.

Meanwhile, meaningful use "hijacked some of the development" going into making EHR products better, Denton said. Or that's part of his theory of how things have gone so wrong. Instead of working on user interface improvements, vendors diverted effort into satisfying the checklist of government requirements to get their products certified as supporting meaningful use, he suspects.

One of the justifications for implementing health IT is that it should reduce medical errors caused by sloppy paperwork and unreadable prescription slips. Again, Denton sees "the potential for that to exist in a well-designed system," but generic software that tries to address every population and medical specialty can actually have the opposite effect, he said. User interface tricks meant to improve productivity can introduce errors. Auto-complete search, where a blank on a form will be filled in with a suggested match when a physician types in the first few letters of the name of a drug, can make it easy to pick the next drug down on the list, after the one intended. As a result, he has seen cardiac drugs prescribed where a painkiller was intended, for example. "So it introduces new potential errors." Even where the software is trying to head off potential errors, for example by detecting potential drug interactions, it is "really easy to get fatigued by all the popups" and stop paying attention.

His hospital uses a McKesson product, Paradigm, and has sunk enough money into it that the choice is unlikely to change. So as head of an IT oversight committee, Denton's role is to seek ways of improving that product's implementation. Yet even though the EHR and related systems at the hospital are all supposed to be HL-7 compliant, they don't share data, and the hospital is still struggling to be able to produce the "continuity of care" documents that healthcare providers are supposed to be able to exchange online in the new world of digital IT.

"Even at our own clinic, we've felt stuck," Denton added. His pediatric practice had to junk the first cloud-based EHR it tried as simply unusable, he said. Adding insult to injury, he wound up paying $10,000 to break the contract and get an export of his own data. Part of the deal was a "gag order," so he can't name the cloud software firm, he said, although "it's not one of the bigger ones." Since then, he has moved to OfficePracticum, but doesn't sound too enthused about that, either.

One reason for his disappointment is that as a medical student interning at Intermountain Healthcare in the 1990s, he worked with an early electronic medical records system custom built for its hospitals and was favorably impressed. While it may not have had every feature of today's EHRs, "it worked in a way that allowed you to really do your job better," he said. "But it's unique to them, and they spent years and years developing it."

In contrast, commercial EHR software has to be generic enough to work in many hospitals and all specialties. The result is a compromised design that doesn't serve anyone's needs really well, Denton said.

Thus, Denton came into the Coursera informatics course wanting to study up on how all this technology is supposed to work. I had to ask if he thought our professor, Dr. Braunstein, was describing a different world of health IT than the one he was living in.

"I think his world exists," Denton said. There seem to be select places in the U.S., probably academic medical hospitals with the resources to invest in perfecting their IT, where positive results from EHR and health information exchange between providers is a reality. But the effect of meaningful use has been to spread the technology across the country into communities that lack those resources. "It's probably a matter of trying to do too much at once," he said.

Follow David F. Carr on Twitter @davidfcarr or Google+. His book Social Collaboration For Dummies is available now.

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Dr.Smith
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Dr.Smith,
User Rank: Apprentice
5/27/2014 | 2:23:58 PM
EHR Software Advantages vs Disadvantages
Dear all I totally agree whatever you guys described about EHR software usage but as a Doctor and I have my own clinic I must share my thoughts with you.

I was not using EHR software in begging but as I feel me and my staff were investing our time on reports, prescriptions, patient details and blah blah .... One day one of my best friend Dr. Gupta suggested me to buy an EHR / EMR software, I start my searching on internet and I found an EHR system provider NORTEC SOFTWARE INC www.nortecehr.com, I contacted with them and I purchased a complete Electronic health record suit for my clinic.

Since that day I analyzed few things positive like .. I don't need to use my maximum staff, All records now on my finger tips, My patients are also happy with our services, Very user-friendly and most importantly I am saving a big part of my earning means better ROI.

At the end I must say there are a lot of advantages in EHR software utilizations.
David F. Carr
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David F. Carr,
User Rank: Author
2/11/2014 | 3:37:47 PM
Re: Is some of the problem with Interoperability?
There's a sequel of sorts posted here:

Doctors & EHR: Can This Shotgun Marriage Be Saved?

 
Aleon22
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Aleon22,
User Rank: Apprentice
1/30/2014 | 2:33:10 PM
Is some of the problem with Interoperability?
From what I see, many issues come from the lack of communication between EMR vendors, labs, and medical devices. It'd be great if all the information was stored in the EMR but many times it's not and so patients information requires multiple clicks and signons to find out what is needed and requires manual input. It doesn't help that EMR vendors can charge an obscene amount to create connections to their solution to send/receive information to/from outside sources. 

Mirth Connect seems to help save costs in many of these areas (I am a sales person for Mirth but Mirth Connect is available as a free open source solution). 

 

 

 
EHRTutor
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EHRTutor,
User Rank: Apprentice
12/11/2013 | 11:45:46 PM
Increased use = Increased appreciation
I recently saw a chart on HealthIT.gov that demonstrated the more in-depth a clinic or hospital delves into an EHR system, the more satisfaction seems to go up. I wonder if maybe the high dissatisfaction that's being reported in blogs all over the internet are caused by lack of training or lack of full implementation? 

Here's the chart if anyone wants to take a look - http://www.healthit.gov/newsroom/america%E2%80%99s-healthcare-providers-are-using-health-it-and-ehrs
David F. Carr
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David F. Carr,
User Rank: Author
10/29/2013 | 10:09:58 PM
re: Why Doctors Hate EHR Software
Do the younger, cloud-based EHR vendors do any better of a job of making their systems usable? Is it just the big enterprise hospital systems docs dislike?
David F. Carr
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David F. Carr,
User Rank: Author
10/29/2013 | 10:08:34 PM
re: Why Doctors Hate EHR Software
Is the business structure you disagree with a result of regulation or the way healthcare organizations have structured themselves?
BillSyrjala
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BillSyrjala,
User Rank: Apprentice
10/27/2013 | 11:37:14 PM
re: Why Doctors Hate EHR Software
The root cause of this problem is the business model of healthcare, and
its protection from competition on cost and quality (unlike other
industries). Until this is fixed, EHRs will be viewed as a cost center,
and not as a strategic weapon to improve cost and quality.

For example, even in settings where EHRs work well and have high
usability, doctors still click through Rx interaction warnings and
ignore them because they take too much time to deal with. Why would they
do this? Because they are not paid for quality of outcome, nor are they
incentivized to minimize the net present value of the 'cost stream' of a
given patient to the system.

So until these underlying incentives are changed at a systemic level,
the never ending tug-of-war will continue between docs and IT in a
largely zero-sum game. No other industry with real competition on cost
and quality would take 20 years and find that only 5% of it's employees
consistently use software (productively) at the point-of-service.
Mr. Gigabob
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Mr. Gigabob,
User Rank: Strategist
10/25/2013 | 6:27:41 PM
re: Why Doctors Hate EHR Software
Tough to disagree with the participant comments. HealthCare IT serves two masters with widely differing agendas - administrators and caregivers. The administrative burden is to provide summary reports and billing coding for insurance and mandated government reporting. Caregivers need easy data input and timely and relevant synopsis and correlation of critical information based on inputs from various sources - for example, conflicting prescriptions from specialists treating the same patient but who are not familiar with what other regimens the patient may be under from other Doctors and caregivers. The point of the EHR was to have a single source of truth provide a global view of what is happening to a patient. Instead we have multiple systems that cannot communicate with one another - creating silos of information. This is what I am hoping the Affordable Health Care act addresses - but it will take time. WIth the Political element trying to destroy better healthcare for Americans it will take even more time. Currently we have "Health Care Systems" built from older IT building blocks and re-purposed for health. They then had to expand to include the regulatory environment, billing environment and somehow lost the plan to build an "ideal" practice UI for doctors and nurses. We need to get back to that and then use IT in the background to mate the caregiver interface with the backend billing and abstract the administrative overhead out of the way of the practice pieces. Ultimately a cloud based system based on universal rules and best practices is where we need to head. Don't see the need personally for coding methodologies and caregiver training to track my flu-shot to differ between Oregon and Alabama.
David F. Carr
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David F. Carr,
User Rank: Author
10/24/2013 | 4:31:40 PM
re: Why Doctors Hate EHR Software
Maybe doctors just like to complain?
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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