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Why electronic medical records are a disaster for some docs

Why electronic medical records are a disaster for some docs

Picture of Monya De

“You’re 56," I say, speaking to a new patient. “Have you had a colonoscopy?”

“Yes, I did, right when I turned 50,” she says. “Isn’t it in there?”

“Well,” I reply, awkwardly. My shoulders hunch over my laptop screen, my hands scrunching to conform to the too-small keyboard. I click and open a dropdown menu. A long list of folders appears, representing scanned-in notes. The folders are differentiated only by date. I start opening them. Right-click. Enter. Oops, ophthalmologist. “X” for close. Right-click. Enter. Nope, that’s a bone density scan, which should have been scanned in under “radiology.” “X” for close.

My patient is getting impatient, and I don’t blame her. “Well, can’t you just search for ‘colonoscopy’?” she asks.

I felt like an elephant had just stepped on me. Our patients, I realized, had no idea how embarrassingly backward a computer-based charting system could be. Electronic medical records (EMR) or electronic health records (EHR) systems are sold with a Jetsons-like promise of a better future. See your patient’s chart from anywhere! Instantly transfer records to a specialist! Electronically prescribe! But in their current form, EHRs are very different from easy-to-use iPads, and my patient had called the software out on one of its many failures.

One big reason doctors and hospitals have adopted EHRs is money. The American Recovery and Reinvestment Act of 2009 authorized Medicare to pay sizable annual payouts – up to $18,000 in the first year – to doctors who start using EHR systems. Medical centers that could invest in the software and training – and financially absorb several weeks of low patient-visit rates – did so. Harvard physician Ashish Jha, writing in the policy journal Health Affairs, reports that more than half of U.S. hospitals now have at least a basic EHR. But, according to Jha, adoption of EHR was far less – “dismally low” – among institutions that don’t qualify for the money, such as nursing homes and psychiatric hospitals.

It’s no wonder there are holdouts. Electronic health records slow doctors down, even after the software is familiar. I’ve watched my own whip-smart doctors cringe, poke and apologize their way through learning EHR systems. Screens loaded slowly. Awkward pauses interrupted the workflow. I didn’t get to chat with my doctors. They were too busy right-clicking and searching for the right place to enter the data.

Many of the doctors I have spoken with over the years have responded with similar frustrations. They throw up their hands in frustration when patients complain: “The doctor was just looking at the computer and not me.” We know. But, if we don’t look at the computer to make sure we’re typing in just the right little box, the cardiologist won’t have the foggiest idea why this patient was referred. A 2013 study found that half of all EHR-using primary care doctors surveyed were spending an extra hour of work on the computer per half-day of patient care.  

When I see a patient in an office that still uses paper charts, the interaction – and the medical record – change. I take swift notes as the patient talks. If, in the middle of discussing her earache, she says, “Oh, I almost forgot to tell you, my mom was just diagnosed with diabetes,” my pen zips over to the relevant area on her intake form. I’ve recorded the new information in seconds. While she continues, I flip her chart to a form – unique to my practice – that contains all her information I might want to see again someday: medications that failed, social issues such as a stressful custody battle, her strict vegan diet.

A quick scribble and her mother’s diabetes will not be forgotten. The note will change my approach to this patient in the future. Freed from time-consuming hunting and clicking, I’ve made more extensive notes on her visit. All of this happens while making real eye contact and getting to know the patient. In an EHR system, entering a bit of family medical history would require me to stop, save, click out of the screen, find where to enter family history, comb through a dropdown menu of 50 different descriptions for diabetes, then another menu of possible family relationships. After all that work, the “front page” of her electronic chart won’t say a word about diabetes.

EHRs do have some advantages. They speed up prescribing and warn doctors when a drug might not be the best choice for the patient. But too often the process of using these good features ends up lost in clunky, illogical software. As someone who studied computer programming and constantly rewrites EHR code in my head, I find it unbelievable that a computer program would flag a drug’s pregnancy risk for a male patient. The saddest part is that a truly intelligent EHR system could literally save lives and increase productivity.

Why, then, aren’t EHRs as easy to use as paper charts? The answer lies in their design. EHRs are designed for medical coding and billing, not efficient patient care. All that endless hunting and pecking to click the right boxes turns doctors into unwilling medical billers, and efficiency suffers as a result of this “second job.” A 2009 study in the Journal of Ambulatory Care Management found that, while coding and revenue improved somewhat after EHR implementation at a pediatric practice, the staff still needed on average 15 more minutes per patient – even two years after implementation. Sadly, after all that work, many doctors don’t even trust the EHR system to properly code the visit.

A colleague recently told me that he was no longer turning up his nose at offers to moonlight in urgent care settings. “The pay’s increasing,” he said. “No one wants to deal with the EHR, plus a lot of doctors are just retiring early.”

Technology is supposed to make our lives faster and easier. We routinely use beautifully designed technology products elsewhere in our lives. All the information and talent to make a great EHR clearly exists. In a world of elegant solutions such as Google and Facebook, doctors and patients deserve a beautiful product that helps rather than hinders our work.

Photo by Ryan Somma via Flickr.

Comments

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Beautifully written! Even harder for us… I'm an ophthalmologist.

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Isn't this an opportunity for entrepreneurs? Why aren't better EMRs, developed with input from clinicians, being developed? If we can't do this via the free market, do we need regulations to govern EMR development?

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I lay in my hospital bed in NJ and read Dr. De's article with a mixture of disgust, humor and curiosity. The article regards electronic health record keeping. Given that as a patient, I love electronic health records, I had to speak on behalf of those similarly situated. My doctors, both in this hospital and my private physicians, use EHR or EMR. (Really the same)

I found that some points made in the article were more a demonstration of an inability to organize then the fault of a electronic medical record keeping system. For example, who organizes files by dates? I didn't do that when I used paper files. Perhaps it might be better to organize by procedure, test results, lab notes, family histories, etc.

If you like your practice's template then make it part of the software. If your software vendor cannot do this then get one who can. It's easier than you think. Don't blame technology because you bought the cheapest version.

It takes too long to make an electronic record? If you can't type get an input system that converts your spoken word to print. Ta da! Like a cell phone! Or write it on an electronic pad that converts your heretofore barely readable writing to typed words. My primary care doctor carries a laptop from one exam room to the next. She sits at a small desk facing me. She gets up, performs an exam and goes back to her laptop all the while interacting with me. She looks me in the eye. She has ALL, OK most, of my info in front of her. Not in five separate paper files. She occasional types a note. Maybe this takes a few minutes linger- but these are minutes she spends with me- not in an alcove writing notes as my doctor did in the 1970 - 80s. It gives her a chance to review everything with me and to make sure she has it all. Likewise, my gynecologist pulls her laptop down from the ceiling where it is held by a mechanical arm. She reviews, examines and records all in the same for me as my primary.

I like this hospital. They have my records held securely. The computer is rolled into my room on a cart by nurses and (some) doctors. My records read and inputted. I have noted that the doctors who don't take the few minutes to read my records are in the dark about a test I had four hours earlier. Results that can be placed in the records with a few keystrokes after interpreted.

The article is correct in its conclusion that doctor's deserve a "beautiful product". Well, other caregivers AND patients deserve it as well. Google and Facebook are great. I wouldn't say "elegant"; but Google and Facebook would probably be the first to say that they can be even better. That's just the nature of technology.

Get a great EHR system after sampling a few. Insist on one which is specific to your type of practice or easily modifiable. Get trained and get your ff trained. Work with your vendor and their training liaisons to improve the product. And believe me, patients want a system that provides access to ALL our records, no matter who the provider's employer.

I am not a computer savvy 30 year old. I am a 57 year old patient that never "studied computer programming" as Dr. De and certainly don't write computer code in my head. Computer code and that whole thing was just starting when I was leaving college as far as can recall. But I am am writing this on my cell phone and when the day comes that I no longer want to engage technology in my work, I will retire.

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As a health professional, EMR are a bain to the independent practitioner. They are more expensive than paper, they make it more difficult and untimely to enter information. EMRs are ways to 'audit' health professionals and if there was a ambiguous case of us not following 'guide lines', then the manager, with no health background and only interested in metrics, can shit can us...

They were instituted to increase the ubiquitous data industries (like google,the Work Number, credit angencies and the Student Clearing House), which rule and ruin our lives by selling our private, important information to prospective employers and graduate schools, making sure we are unable to ever make a mistake and still remain employable.

Oh, and EMRs, they also make it impossible to be honest with our doctors. You ever have back pain, used drugs (including drinking/smoking), have a family history of CVD or cancer, keep it to yourself. if you ever want to join the military, work in police work, or want medical insurance. Instead of the seven year retention period we used to enjoy with our medical records, they are now kept for life. You will be punished to see the doctor. A military recruiter recently told me that only 10 percent of the population is eligible for military service. All those kids going in are either too young to have a medical history or more likely lying about it. Universal EMRs haven't come on ling yet. Get ready for tens of thousands of career military to be dishonorably discharged, which shows up on criminal background check, rendering them more unemployable VA basket cases...

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I can't get my doctor to change mistakes in the on line records from the past. I know my record from other times (my childhood) places and diagnosis better than he. How dare they put mistakes in my record and not remove them when asked. Future diagnosis depends on it,. I'm feeling like big brother and want out.

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I for the life of me outside of sheer laziness can do not understand why medical information isn't just kept in one universal system for all doctors to have access once granted permission by the patient. Why can't we have a universal medical record system used by every hospital, care facility and doctors office? I just went through a very traumatic pregnancy that ended in the death of my baby due to a medical condition I never knew I had. A condition that i was diagnosed with as a small child that my recent doctors never ever knew about. The care I received because of the lack of information sharing between my medical team was substandard. I know without a doubt that I would be rocking a baby to sleep right now if we had a cohesive system that kept everyone in the loop. How am I, a 23 year old student, supposed to know about my health record from when I was 2 years old? What am I supposed to do when family history recorded by mother is not found on my new records and have no idea what is going on? It truly baffles me that we put so much emphasis on privacy and liability when people are receiving messed up carw based off foggy memories. And then to tell me that doctors don't even keep cohesive notes and there are errors? What is the purpose of tracking and taking notes if I can t access it later? Why ask me for my medical history and family history if they will never use it? My baby is dead because of these horrible notes kept by our medical profession and to be honest, I feel absolutely betrayed by my provider. I don't trust my provider and honestly thinking about just leaving traditional medicine and seeking all my care in alternative health.

Someone above said it's a ploy to keep tabs on doctors and to give them a hard time, I say why not. I would have a beautiful 1 month old to hold had my doctors had consistent notes. You understand how pissed off it feels to have to explain your health problems over and over and over again to someone after you have the same information to another doctor a few months back. It just seems doctors just want to show up and get a check. Having all of our information in one place would solve a lor of problems. Why they just don't have one unified system is just crazy to me. It's 2016.

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I find that almost every time I go back to a doctor that they have just "updated" or "upgraded" to a new system. So I then have to write down all the information I provided last visit on a form that someone in the office then has to enter into the new software. This is highly inefficient and drives up health care costs for insurance and patients.

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I just can't understand why this is not ironed out and typically used in our health care system. My doctor had to ask me about previous procedures! When I asked why he didn't have them he said it would be difficult to find them and that many other doctors and medical facilities do not forward the results to him. Then said that it is the patient's responsibility to make sure they do it! You always give the name of your primary doctor, but you are not in a position to make office staff follow through! This is archaic in such a savvy electronically world we have today.

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