Of course, blame the software, blame the devices, blame everything but a doctor, or a PA, or a nurse who is too lazy, or too stupid, or too stubborn to learn how to use a keyboard and talk to a patient at the same time.
It really doesn't matter if the new technology is to make record-keeping more accurate (and prevent errors when those records are shared); or to make the billing more efficient (&, yes, profitable); or to ensure that prescriptions are filled properly. What matter is the technology is here, and sooner or later medical workers will need to master it, just as they had to master automated pain-pumps, and MRI and PetScan systems and software-driven ICU monitoring units and bypass machines and camera-equipped probing tools.
This piece is a sop to those fantasists who actually believe there were good old days; when all physicians resembled a Norman Rockwell painting; it's a hymn to nostalgia. No doubt when the stethoscope arrived, there were doctors (and their journalist sycophants) who complained that listening to a patient's heart had become so impersonal--why wasn't putting an ear to the patient's chest good enough?
If your doctor loses his clinical judgment while entering your vitals into a tablet, it's the not the tablet that's the problem, It's your doctor.
1
I recently spent roughly 10 hours a day for over a month at a relative's bedside in a major academic hospital. The doctors and nurses were some of the most dedicated people I've ever met, but I was struck daily by two things -- they were forced to spend more time looking at their computers than they did looking at their patients. And nobody really had the job of synthesizing all that specialized information and treating the whole patient. I've been part of other digital transformations and they can be very bumpy. This one certainly is. We need to fix it, as soon as possible. Thanks for a terrific and important article.
4
My husband is a physician in his early 60s and I used to think his medical residency was the worst part of his career (in those days they worked 36-hour shifts with 12 hours off [and the latter was even a fantasy]). However; as an academic physician, he's still working nearly the same number of hours (including some weekends and many holidays) and it's untenable at his age (if his medical specialty wasn't one of the lowest-paid, he'd seriously consider retirement - and that brings up another issue, which is the myth that all doctors are paid obscene salaries. I want to laugh [or to scream] when I hear people rant about that topic). Also; it's not just the sheer hours, but it's also the *stress* of having someone's life in your hands - and having insurance companies breathing down your neck (and having their bean counters *continually* question your medical decisions, thereby necessitating spending literally *several hours/day* on the phone with your humongous patient load).
Patients have the misconception that physicians are glued to their computers out of choice, but that is *not* the case; it's the reality of how doctors are now paid in this country. Certainly EHRs provide much faster (and decipherable) access, making them much more practical. However, it's misdirected anger to blame physicians for what has become of American medicine.
My husband is an exceptionally compassionate and kindhearted physician, but our current medical system doesn't value that.
9
Doctors have themselves to blame, really, because they were so slow to move from paper that the EHR was designed by managers who expanded it from the coded billing systems. It was never designed from the ground up, to be a medical record.
And the doctors didn't think of automating soon enough to develop one standard so that we could ship records safely electronically; nor in a lot of cases do they want to.
But of course the record can be maintained without having one's back to the patient: but you might need scribes or you might need dictation. We always had medical records that needed to be filled out, and we always had code sheets that needed to be submitted to billing. What we did not have was a single doctor who needs to see a patient every five minutes.
The real threat to medicine is not the record, but the drive to efficiency standards that ignore that doctors and nurses are the capital assets, and that patients are the primary concern. Instead, we have the same managers who installed the EHR driving low headcount and high patient turnover. That is not the fault of automation - it is the fault of profit taking. It is the fault of believing medicine - like other human centered services - can be driven and managed the same way that the robot punching out car doors can.
Don't blame automated records systems - blame the healthcare industry.
2
"The real threat to medicine is not the record, but the drive to efficiency standards that ignore that doctors and nurses are the capital assets, and that patients are the primary concern." - I think you've nailed it. It's always about money. The EHR is a tool. There are good ones and bad ones, but it's not the tool's fault, and the problems in medicine aren't because patient records went digital.
1
It is ironic that the careful physical exam that Dr. Verghese advocates and which he accurately describes as "a marvel of fiction," is in fact used by managed care entities to "upcode" the risk profile of patients to game public programs like Medicare Advantage to get more taxpayer dollars. Dr. Verghese and other academics have just discovered physician burnout ( when this paper has been reporting "doctors in distress for 30 years or so) and turned it into a grant-supported cottage industry. Academic medicine helped encourage the very burdensome form of EHRs that have contributed to the problem. Academia and the Robert Wood Johnson Foundation rejected a doctor and patient friendly form of EHR we developed at Duke 50 years ago that allowed doctors to generate reports while encoding important prognostic variables and compulsive and comprehensive outcomes data that empowered shared decision making. Then as now, no one wants to pay for the collection and monitoring of real clinical outcomes. If doctors were engaged in this at all levels of training and practice. the joys of medicine would be experienced and patients given real-time advice on their prognosis and treatment plans. User friendly clinical registries are a solution to improved doctor satisfaction and patient care.
4
What is most interesting about the electronic medical record, as currently constituted, is that no one reads what is recorded and the notes written don't actually provide useful information. Instead there is a torrent of jumble that is repetitive and unhelpful in understanding the patient's complaints and, in many cases, disguises the correct diagnosis. What is also not clear to me is why physicians accept this perversion of the medical record. Collectively we have the power to change it. Don't "burnout" or "retire". Force change!
6
Great analysis. I would like to add: Every little thing is considered emergent. The motto “quicker, the better” is imprinted on the brains of young residents. “Time” as a diagnostic as well as therapeutic modality is being used less and less. A lot of so called data would change or disappear with “wait and watch” approach.
1
Beautifully done. Thank you.
3
Much of the "burnout" physicians experience from use of EHR's is caused by the excessive regulatory burdens placed by well-meaning bureaucrats. A recent paper by Downing, Bates and Longhurst in the Annals of Internal medicine contrasted average length of progress notes by US physicians compared to notes from physicians in the rest of the world. Notes by US physicians were 3-9 times longer. The authors suggest that regulatory burdens are responsible for excessive documentation requirements. The solution - reduce regulations and allow doctors to practice medicine, and not require them to spend inordinate amounts of time documenting the care they deliver.
5
Unfortunately people are blinded by the notion that progress is always good. The gods of our ethnological world are efficiency and profit. But in worshipping them we demean human beings.
3
what a wonderful essay written by someone who Cares.
5
These sham systems don't exist to improve medical care. They exist to allow fraudulent "up coding" of notes to maximize charges and allow instant billing. Our system does not allow signing the note until we have billed! I can look at my "Dashboard" to instantly see how much I am billing per patient visit and my cumulative billing over time.
They create stressful clerical tasks for the providers, but ensure those million dollar sick salaries for our physician "leadership". The whole system is rotten.
3
Thanks for sharing your thoughts. I agree the only metric that matters is LOVE. In this regard, I would like to bring to the attention of all the services offered by a hospital - Sri Sathya Sai Super Speciality Hospital - in Puttaparthi, India where there are all kinds of departments - cardiology, Urology, etc but no department for BILLING. All of the procedures including cardiac surgeries are FREE. The spirit moving this great institution is LOVE - Love All Serve All, Help Ever Hurt Never
2
Talk about Baby and bathwater. Yes if you let technomorons build heath care systems you get junk. I have documented this since the 1980s. but when you involve practitioners in every step of the design process you get a tool that can revolutionize medicine. I know I watched my wife develop such systems over the past 30 years. as a physician Computer expert she had the skills to make the system the Drs best friend.
2
Machine learning, as it is currently understood, is very dumb learning, based on multiple trials. Patients and their problems are to individual for this to work well. A doctor has to be able to read a document, and immediately and permanently change their behaviour. Semantic processing can handle this. As to the human-machine aspect, humans have a very low limit on how much information they can process - no more than four pieces of information in play at once, resulting in many poor, or in medicine, fatal decisions. The hundred thousand or so unnecessary fatalities in US hospitals each year attest to overstressed people, often overworked, tired or bored as well. Machines don't have this limit.
Any appt. with an internist is now an experience in 'Beat the Clock.' Highly stressful and unproductive for the patient, and in some (many?) instances, also for the physician?
And then there's the 'hospitalist.' That new-ish wrinkle in ER and in-patient care. Because, of course, the place you want to start all over in your medical life and history is in the ER with a stranger.
We all need vials of the 'good stuff' to just ease ourselves out. I mean, medicine is pretty much 'self-service' already, why not just make it official? And simpler?
It's not all that surprising that doctors are finally being displaced by AI. Even professors (!) have long been nothing more than clerical workers.
Wonderful piece that captures the inchoate frustration that doctors feel every day, trapped in the maze of discrete data elements that constitute electronic charting. These drop down boxes, mouse clicks, and check boxes allow easy analytics, but the input is, as he has said, garbage. An oft quoted study says that of those 4,000 clicks in the ER - about half are false, and just clicks to get past best practice advisories, interaction alerts, med rec alarms, and so on. The customer was always the hospital billing and compliance offices, it turns out, sadly.
2
" And what all of us in the trenches — housekeepers, nurses, nursing assistants, therapists, doctors — have in common is that humanity. We came to this for many reasons, but it sobers me how many people came because they had a sense of calling, because they genuinely care."
You forgot the role of the hospital administrators, et al, who will fire you if you don't bring in the bucks, to pay for the glorious new profitable illness wing. And don't forget corporations like Press Ganey who rate and fire doctors because the complaining patients didn't get enough pain medication.
3
There are many problems with medicine as practiced in the US today. One of the more obvious is your comment on the financial loss to the system of a physician (a million dollars). Even physicians who purport to be good doctors see the loss of money to the system as bad rather than the despair of a person who had hoped to dedicate their life to a soul fulfilling profession of caring for the sick and injured. The American physician is instead a cog in the wheel of a scheme that makes each patient a widgit to perform more tests on, generate more income to provide more incomes to more people. Meanwhile we as a nation have dismal health outcomes.
Hurray for for-profit, cookbook medicine. We have just buried a noble profession killed by greedy, free market administrative types. Next stop, collapse and finger pointing.
2
In it's essence, healthcare's focus upon EHRs is simply "Plantation Healthcare", where the net benefits accrue to the landholder (dataholder) and not those who toil or participate within the data landscape.
This is the direct result of the marketplace that has been formed around health care - in exchange for purported "innovation" and "efficiency". Until this marketplace is dismantled, we'll all be just pickin cotton in some form or another.
1
I think doctors will become more managers rather than actively making independent decisions. Very similar to pilots. Pilots once required incredibly highly intelligent individuals, but now planes can all-but fly themselves. So we monitor systems rather than making "gut" decisions. Same with doctors. I would image most illnesses are well documented and have standard treatments. Thus the rise in physician's assistants. Less skills and training but can now serve in the exact same capacity. Professions dry up and die. If someone wants a human-touch, see a masseuse.
This article suffers from medical parochialism and a lack of a comparative perspective.
* The notion that somehow clinicians are being subjected to excessive work on the computer needs to be understand relative to other professions.
* In particular, "4,000-key-clicks-a-day"? A page of typed text is about 3,000 characters. Perhaps what is being talked about is mouse moves or checkbox toggles; even if that is the case, I have read that many professionals move their mouses between 5,000 and 7,000 times/day. Given the long shifts clinicians subject themselves to, I doubt that their work is any more computer intensive that any other customer-facing service industry. But facts here across the professions would help.
* And a comparative perspective would also help with the claim about burnout. Really, doctors suffer from burnout? I'm shocked, shocked! I reckon that every profession in the United States would claim that its workers suffer from burnout.
* For doctor burnout: We really want to circle in on the EMR? What about doctors working two shifts, etc.?
Physician, heal thyself.
Please do not lump electronic health records with artificial intelligence.
Electronic record-keeping is incredibly powerful as a tool for the ability to know everything about a patient, at all times, in real time. The problem has been the EHR software companies which have been feeding at the trough since the ACA provided funding.
EHR software is proprietary. Each program is different, and proprietary apps cannot communicate with each other to any significant degree. It has long been known and advocated that these programs must have "interoperability" built in, yet little to no progress has been made on this front.
Use "machine learning" to solve this problem and we'll be in business.
Another well-known problem with EHRs is that doctors and other clinicians lack the computer skills to make full use of them. Healthcare groups and institutions must invest in the training necessary for all clinicians to become facile using these programs.
2
Verghese has a habit of blaming technology and supporting the image of the doctor of the past.
The truth is both of these have their relevance and it is easy to dismiss one over the other.
We need voices from both to try to find a balance between the two. Medicine is messy and this will not be an easy task.
One simple step that can redress the imbalance is to reduce to the number of patients seen or increase the encounter time so that computer entry does not have to dominate the clinical encounter. This may affect profits but profits should not be the highest ranked goal.
1
If I was a patient at a hospital such as Stanford Medicine, is there a way for me to get ALL the data entered about me, so that the unintentional or intentional (due to "upcoding") errors can be questioned and corrected before it does lasting damage? For instance, I would like to share that information with trusted family members or friends who happen to be physicians, but can not be physically present.
1
I am a GenX doctor who has seen every variety of medical documentation. For me, the largest frustration is that "IRL" I can google and find anything but in the EHR it takes a million clicks to find the data I need. At times I end up clicking in and out of documents as I compile the data on a piece of paper to integrate certain trends over time.
I believe the issue is that capitalism has failed in EHR development. Hospitals have put so much money into a few systems that there is no room for an innovative new product that will improve patient data collection and analysis. I joke that I would sacrifice my first born to prison if he could hack into EPIC or Cerner and bring them down. It would open the market place to radical new products that would be a vast improvement on the current state of affairs.
2
I was a pretty good oncologist, I think. Careful, empathetic, hardworking. It was what I did
After 25+ years in the same community, while still in my late 50s ad in good healh, I left medicine late last year.
From my retirement remarks:
"There’s no denying that another substantial factor in my decision stems from the grief involved in watching the job decay from a service-oriented, respected, time-is-valuable professional into that of an overtrained data entry clerk. My time in an exam room or on the phone with a patient has intrinsic moral value; my time inputting into, wrestling with, or waiting for a computer record does not. We may have collectively been bullied into accepting this as a current requirement for our jobs, but frankly it’s not worth my time."
There aren't enough oncologists out there. But I'd been shoved around a little too far. More to the point, the environment I was in no longer allowed me to do the best job possible.
The war on cancer is over. The drug companies and the health care systems won.
12
Well, we're the ones who put the politicians in charge of healthcare rather than the doctors. And we ain't ever gonna admit that was wrong. In any case, this problem solves itself when the generation of doctors who knew something different retires.
3
I am a 68 year old recently retired Stanford medical graduate. Medicine was not my job, not my career. It was my calling. And yet I confess I left after 40 years with overwhelming relief. I bowed under the burden of working two distinct shifts every day-- the patient care shift, which I enjoyed and did well, and the data entry shift that followed, especially if I chose to attend to the patient during the encounter rather than the screen.
11
Typing into an EHR with an patient in the room is like texting while driving. Its potentially very dangerous but unfortunately a necessity unless you want to spend many extra hours of hours catching up. Scribes are a possible solution for some specialties but not all.
12
One serious problem with EHRs is that they aren't designed around the needs of doctors, nurses, and other "providers" who interact with patients. Rather, they're designed to serve the much more important needs of administrators, billers, insurance companies, auditors, lawyers, and numerous other actors in the Business of Medicine. The needs of "providers" are not important to EHR developers because they're not the customers. It's almost always the administrators who buy the EHRs. So developers understandably strive to make their products attractive to MBAs and CPAs rather than to MDs and RNs.
EHRs that serve the business of medicine rather than medical professionals are just pernicious aspect of a medical-industrial complex focused on the wealth of executives and shareholders rather than the health of patients. The physicians, nurses, and other professionals who used to be in charge of health care have been demoted to fungible "providers." These "providers" are assembly-line workers, the lowest level of a hierarchy ruled by managers and executives of corporations whose purpose is to create "shareholder value." The patient, of course, comes last.
EHRs designed around the needs of doctors, nurses, and patients could likely improve the quality of medical care for patients, and possibly even improve the practice of medicine for doctors and nurses. But none of that matters to a business exclusively focused on maximizing profit for executives and investors.
18
The last time I saw a GP in Australia - for about 12 minutes - he probably spent about 8 of those minutes typing into a computer - at the end of which he handed me a few printouts.
I got the feeling he felt more like an administrative clerk than a health care professional.
But hey – computers are great – I got pages of information I wouldn’t otherwise have had – including my cardiologist’s detailed report – my blood test results – loads of data which is easily sent by email between pathologists and providers – so that’s good.
I have recently been involved with helping some friends with their doctor appointments. A s a retired doctor (from the old school) I am surprised and upset about what I see. First, the records are better and are accessible but I see that most of the docs did not bother reading them before the appointment. The appointment often was them reading and catching up on info that was on the computer. They had not prepared for the appointment. Next, no complete examination and often no hands on exam.It was a computer reading session. Often one specialists had no idea that the patient had another problem (eg. had prostate Ca but did not know that bladder polyps removed 2 weeks earlier. No history was taken except how do you feel? After having radiation Rx. for prostate cancer the cardiologist did not even recognize there was no PSA after 6 mos. It was very fortunate I was there to address these problems and to have things ordered. Computers or not Docs are not doing a good job with patients.
11
The writer is quite correct in the dehumanizing of healthcare. However, he doesn't mention the Fee For Service model that fed the problem to the place where it now is. As doctors have an incentive to order many diagnostic tests in the interest of billing more as fees for service. Many years ago this didn't allow for such billing, but was only referred to as "buffing the chart". The EHR has assisted in the corporatizing of our medical model.
1
Clinicians check boxes for work not done in order to get more money, so EHR data leads to problems when people believe it. This doesn't sound like a problem with not enough physical contact with the patient, it sounds like clinicians deluding themselves by obsessively checking boxes. It's true that AI is not developed enough to make good use of all the EHR data or to help generate it automatically from cameras and microphones and body sensors or avatars questioning patients, but without the data you can't start to develop the AI. And if you're feeding in fake data to get paid more, the AI will learn to do the same. In order for data synthesized from all the disparate vitals monitors to be useful, the synthesis has to be trustworthy and that's not a single problem, it's many problems that depend on the medical context. So expect AI's to start small, becoming useful for simpler synthesis tasks, and to grow and get better with time. At some point in the future (far future more likely than near future) the clinicians main remaining task may no longer be diagnosis but a focus on the patients feelings and comprehension of what is happening.
The boxes come prechecked. The diligent clinician must then UN-check every false box, and it's an enormously tiresome job. The EHR companies make it the way so their clients (management) can bill more.
As an educator...welcome to my world...tech has turned me into a clerical worker who must constantly weigh my performance rating and the need to prove I am effective, against my true job as a teacher. Those who think data can identify the needs of my students- You are wrong. Sure. I can turn my students’ assessment scores into a number for a spreadsheet, but that does not accurately predict their future growth. It will not accurately fuel my instruction. Nor should I, as a patient in need of health care be seen as another data entry for my Dr. Never forget the true assement gained by one on one communication.
3
I live in Japan with a single payer system and excellent electronic health record system. Personally, I can't praise the system enough. What it lacks in personal warmth it makes up for with efficiency, thoroughness, and cost. Doctros work hard here. No daily extortion tours of the hospital, doctors are salaried as they should be. Nurses and other clinicians do most of the work, the AMA guild's hold on the medical industry is one of the major reasons medical costs are so high.
8
I applaud (for once) the Times for writing an insightful article on modern healthcare. Our system is broken. The EMR is really just a fancy billing system. The EMR called EPIC is a cash cow for the Bush family. We need a single payer system. Period the end. No matter how much time we spend with our patients we still spend an enormous time charting. This was true as an RN and hold true now as an NP. My EMR helps me care - reminders, hard stops, but hinders me as well. EMRs are linear, health care is a sine wave - perhaps better coding would help.
4
Welcome to the experience of the rest of the American workforce, physicians! Metrics are useful in small doses. But the way companies are in love with data now is crazy. Inputing measures to the algorithm has taken over doing actual work!
4
get read of the many many insurance companies whose only role in the healthcare system is to deny care and a big chunk of the complexities of billing goes away. single payer, one form for claims.
13
Unlike many veterans, apparently, I've always been satisfied with the VA Clinic in Eureka, though sometimes doctors from San Francisco must do teleconferencing with patients because there are none currently on staff. But when I have been in examination rooms with physicians, I've noticed how much more attention they have to pay to their computers than to me. and whenever they're oldies, like me, the doctors often have to struggle at it.
4
The problem on requirements for excessive documentation has been around longer than the E.M.R. In my opinion, it dates back to the decision by C.M.S. (if I recall correctly) in the late nineties to standardize documentation for billing. At least in my specialty, neurology, an extensive exam is generally required for billing more complex cases. In addition, the rules for billing documentation are so complex that they cannot be applied reasonably in a busy clinical setting. You end up guessing your billing code, and documenting everything to make sure you aren’t considered to be overbilling. Prior to that decision, you documented the important positives, negatives, and conclusions. It was less busy, and far more useful. The EMR exacerbates the problem as it is cumbersome to document what is actually done. The combination takes attention from patient care.
7
I am a senior ophthalmologist practicing in a city with an overall excellent medical community. Last week I saw a young woman with a two month history of headaches who had been to the emergency department twice. She had been seen by several physicians and had tests including a CT scan of her head. She was told that there was nothing seriously wrong and referred to a neurologist who would not see her in the ED. At her mother's request I saw her and found that she had bilateral papilledema or swollen optic nerves that indicated increased pressure inside her head. It was the worst swelling I had seen in over twenty years and something that should have been picked up by any physician who bothered to look inside her eyes. I have not reviewed her hospital file, but I'm certain that it would contain the computer-generated notation: "HEENT = WNL."("Head, eyes, ears, nose, throat all within normal limits.) As physicians we have become slaves to our EHRs. I'm praying that the generation of new doctors who will care for me when I'm in need will bother to treat me as well as complete their electronic entries on my chart.
35
I am a physician. My primary doctor is excellent. She somehow manages to use the EHR and still look me in the eye. I am always behind in my own charting because I speak to the patient and then do the EHR. It is so time consuming! There are definite advantages to the EHR but the handwritten note, if legible, is so much more efficient. I was recently referred to a hematologist He is probably in his 70s. He started from the beginning with my history. He did a full physical examination and he figured out my problem which he confirmed with laboratory tests. I appreciated it and told him so. Like other commenters I have seen several physicians who didn't bother with the examination. It embarrasses me to admit that I didn't challenge any of them.
19
Please, doctor, NYT and anyone writing about people in clinical medicine, drop the term "physician" and substitute "clinician". There are thousands us "non-physicians", PAs and FNPs among many others. We are all doing the same thing and experiencing the same problems with EHRs. We are NOT "physician extenders", "providers" (oh how I hate that terminology), or "mid-levels". We are clinicians. We are everywhere. We are not invisible. We do good work.
7
Why should we drop the term "Physician"? I spent 4 years for an undergraduate degree, have a masters and a Ph.D. in Molecular Biology, then spent 4 years in Medical School followed by another 4 years in residency.
You might be everywhere, You might do good work and you are not invisible. However, you are not a physician.
3
There's really nothing wrong with the term "provider." The term is actually used for exactly the reason you say - because not every provider is an MD. So why would you object to it? Not every provider is a clinician, either. Healthcare consists of a lot of different services, not all clinical.
I think the problems described in this article with EHRs are only temporary as I haven't been using them for 10 years yet and our clinic adopted them as soon as they became required by Medicare. Our exam rooms do not have computers in them because the machines will be stolen or destroyed by patients and their children. I take in a yellow lined pad, face the patient, ask questions, do the exam, and refer to my notes when I fill in the EHR.
1
Well, I have been using EHRs for 10 years and the problems have not been temporary. The only difference is that over the years they have piled on more and more useless check offs.
11
Friend, don't complain about the word "doctor" or 'provider" then in the next comment endorse that you haven't been using an EMR for 10 years yet..... When you really get some experience, write back with some suggestions. JUst saying. From a fellow "provider."
1
Our EHR gets worse and worse every year as the add more junk to it.
2
Uh-huh. If only we had not gotten rid of buggy whips, our transportation system would be so much better.
3
Clearly not someone working with an E.M.R.
2
You completely miss the point of the article. To put your analogy in proper context, imagine if the early cars were designed to satisfy not the driver or passenger but the city lawyers, a team of fat cat auto executives, data hungry administration, and insurance industry. I bet you would have wished for a comfortable buggy. Do you work for epic by any chance. It is very hard to convince someone against their livlihood.
3
If we didn't have cars and trucks and buses....we would still be riding horses and wagons pulled by horses (or mules or oxen).
And the air would be clean and there'd be no global warming.
So maybe the buggy whips were a good thing, after all.
For a number of tears I worked in the IT department of an HMO in New York. Our main 'product' was a case management system that followed all the members in the plan, aggregated all the information in their EHR's and determined which ones were considered high-risk cases. Those individuals would be assigned case managers -usually RN's - who would prod and harangue them on the phone to ensure they were taking their meds and keeping their appointments. At the same time, the system was keeping track of the case managers, recording every interaction in excruciating detail as they were required to enter 100's of fields per case and intervene in dozens of cases per day. The amount of stress this supposedly benevolent system caused resulted in a curious state of affairs. While the case managers were spending all day cajoling diabetics about food choices and smokers about quitting, they were penned up like cattle, generally obese and also the heaviest smokers in the organization.
10
This article is nonsense. First, a doctor who doesn't show up at your bed and fails to lay hands and eyes on you is simply practicing bad medicine. This has nothing to do with Electronic Health Records. Second, my primary care physician does not spend his time making 4000 keystrokes. With the patient's permission, exams are recorded, and later transcribed, by a specialist, into my medical record. It's great because my doctor enunciates every single finding, so I know exactly what's going into the chart. Third, I go to a large medical group with many locations in all specialties. My electronic records are available at all of these locations. Yes, it's a problem that in an emergency, if I'm traveling, this record is not available. It should be. This has nothing to do with the idea of maintaining such records but a failure of the medical establishment to standardize. During his diagnosis, my doctor will for example, compare numbers for blood pressure or chemistry across years. It's a great tool. Fourth, the real problem is that doctors fail to apply AI to the information in order to make tricky diagnoses. The Times often has articles about such cases. The patient may have a disorder that a doctor will never see in a lifetime of practice. This is where a computer is useful. Fifth, if a doctor is swamped with 'clerical work', his or her practice is doing something wrong. They should fix it.
6
That's some progress in your situation-- many practitioners are considering scribes to enter the data, but fewer actually have them (not free!). And your large medical group is a benefit when you are in their network, but how much of their data will be available to another hospital or medical group even across town? It's unfortunate that most physicians/NPs/PAs have a daily life much like what's described in the article, and it absolutely is driving our burnout and dissatisfaction with the career many of us once loved. I am learning to type much faster at least...
5
to Cupcake: Thanks for your comment! The idea of the 'two shifts' made it very clear what your life is like. If you put the two of our comments together, I think what you get is that solutions do exist to fix these problems. In particular, formats for health information SHOULD be standardized in a way that all medical data can be shared. Such standards exist in many fields, but not medicine. Second, audio transcription should be adopted generally. There is no reason why someone else can't do your 'second shift' work. A transcription specialist should be doing it. I have seen this work well for all the doctors in my medical group.
2
Your ignorance of the way a private solo medical practice is actually run is appalling and frightening. Big hospitals and their minions are far worse.
2
With 'meaningful use' and 'value based care' healthcare systems are reimbursed based on their metrics. How many PHQ-2s and PHQ-9s did they do? Did they do an ROS of 7 or more body systems? How many diabetics have A1Cs below 7? EHRs are designed to capture those metrics and make them billable.
If the goal of EHRs were just to capture physician and nurse notes on an electronic database, they'd be immensely popular. But they're not. EHRs were designed to collect data which could be used for billing, because billing has become much more complicated with the ACA. Unless we're going to return to fee-for-service, someone needs to make an EHR than translates a free text note into something that is searchable and billable.
8
Idiotic billing complexity predates ACA. The crazy 2 bullets from 9 system physical exams started under Bush. I hate going to work and will retire from medicine just as soon as I can because of it
4
You hit the nail on the head ! There is no difference between a doctor using a computer to check all the boxes so that the billing office can calculate the charges for your visit and the checkout girl at Target. As several others have already commented , their accuracy ,as far as the pt. having any particular part of an exam , are often inaccurate .
4
This article from a physician who is clearly burned out is not informative or helpful for the broader conversation on how we can improve healthcare in terms of improving quality, improving patients' experience, improving workers' satisfaction, and reducing cost. This user's poor experience has clouded his judgment and what he contributes back is a screed that is about as useful as spitting into the wind. I don't think anyone admits that the systems are perfect; hospital IT departments are always looking for doctors and nurses who are willing to invest time in helping to make the systems work better. When they refuse to help because they aren't getting paid enough to do so, that's when it crosses the line into whining. Plenty of avenues to help yourself and others, doctor, but you would rather invest time in trying to convince people to stop using EHR's. Good luck with that.
1
From what you are writing, you are part of the problem.
4
Only had to read the title: we primary care doctors have been saying this for years. Nobody cares. I tell my patients the future will be AI: a robot will take your symptoms, pump them through an algorithm, and give you some medication. My fellow PCPs and I will confine to type away our hours and days. Our own health goes down the drain while we seat to make sure we type all the necessary information. And everyone keeps looking at their phones....
18
Yeah well we're paying almost 20 PERCENT of our entire gross national product for outcomes that are not as good as most other industrialized nations so maybe doctors should be "clerical workers". Remember we're paying MORE THAN TWICE AS MUCH as the next highest country in the WORLD (sorry for yelling but Americans are like sheep on this issue).
Medicine should be a science, not an art and ultimately I hope that we'll have A.I. that'll take one look at our immune system and DNA and within a few hours or days concoct a bioengineered fix for cancer/heart disease/alzheimers. For accidents, a good 3D bioprinter with a robotic surgeon will put in the broken/missing pieces.
Just like Star Trek "Voyager" where the "Doc" was a hologram.
I'm an investor in a BioTech startup doing immunogenetics and yes we use A.I. to help recognize which cells are cancerous and which are not. Our goal is to let the incredible power of the body's 100 billion self-replicating machines called "cells" when tweaked by CRISPR get rid of the cancer. As the recent genetic therapies approved by the FDA have shown, there are CURES for these diseases on the horizon, in that case I'll be happy to be a "clerical worker" just filling out the forms to get the appropriate treatment. As with any new technology, it's expensive today but as the costs of sequencing (down by over a factor of a million in the last 15 years) and other techniques continue to plummet, I don't see why this won't become widely available.
1
Let's see how you feel when you or a loved one comes down with cancer. I"m sure you will be very pleased with Dr. Hologram and Nurse IT.
13
With all due respect, you have no clue! Medicine is an art, it will remain an art and science is merely scratching the surface of it and always will. The human organism is far too complex to yield in a 100% predictable manner to most, except to a very few, interventions. That's why we have clinical trials and that's why 99% of them fail to result in a new FDA approved medication! Science tells us a specific intervention should work, but when we test them in humans we find that either they don't or that there are intolerable side effects.
The physician who understands the art of medicine and knows how to use the imperfect science of human biology and medicine to maximal effect will be the most successful. The technocrat, who dismisses the art and only relies on the "science" will generally fail.
17
And what color is the sky in your world?
1
Well put, as always, Dr V. This situation is the current state of a now 30 year arms race between payors and providers. It began in the late '80s when Medicare decided to base reimbursement not on what was wrong with the patient but what you "did." This was not in itself unreasonable, but "did" really turned out to mean "documented," and so we had to ensure that we wrote down review of 11 different systems and 6 elements of past medical history, 5 of social history and examined 13 body areas (I forget the original numbers, but you get the idea). And if you didn't write these down, then you were defrauding Medicare, no matter what you had actually done. So paper templates were invented to prompt attention to all the (billing) details. Then computer technology allowed docs to say "you want documentation? I'll give you documentation!" And the data wars took off in earnest---and doctors and nurses literally turned their backs on patients.
People forget (and administrators and lawyers are flabbergasted to be reminded) that you can save someone's life without writing down one single thing---and no matter what you write down, if you don't actually DO the right things, the patient will die.
Ah well, at least we don't have to play the old games of "who's got the chart?" and "where'd that x-ray go?"
13
Part of the problem is utter incompetence in the producers of the software. And that descends from similar incompetence in software production everywhere else. Managers don't understand what is being produced, marketeers want flash, and software engineers, even if competent, are functioning on limited information. And when the bureaucrats and bean counters get involved the usability descends to zero. Software is literally causing society to grind to a halt, because of the inability of ordinary people to use it, and the lack of technologically competent people to maintain it.
13
What we have are " Software Programs " designed by people who will never have to use them . Not too dissimilar from Govt. rules which our nationally elected officials don't have to follow.
9
I just completed my residency much like the doctor mentioned in this article, and can attest 100% to the author's account. A survey done in my residency showed nearly 50% met the technical criteria for burnout, and nearly every person had some level of cynicism. How do the electronic medical records contribute?
They are not designed for healthcare providers or to improve patient care. They are designed to maximize billing and to avoid lawsuits. Over 75% of my note is useless autofilled information that nobody reads. Consequently, I often overlook these parts causing "errors" or "false statements," which in reality is just not wasting time filling out useless information nobody reads. I have literally developed carpal tunnel and lower back pain from sitting at the computer all day typing.
To be fair, in medical school we still had paper notes and I hated them. They were impossible to read and conveyed almost no information to anyone but the author. However, we have now gone in the complete opposite direction where literally everything must be documented, which I also hate. Where is the middle ground?
7
carpal tunnel ? I had radial tunnel - shooting pains up the underneath/outside of my R wrist from my little finger - and assumed it was from keyboard overuse - until a Filipina student of computer programming told me she would never ride motorbikes as too many people she knew had broken wrists in motorbike accidents and subsequent carpal or radial tunnel problems.
I went wow - yeah - my motorbike accident broken wrists - that's where the pain is - so - if you suffer from carpal tunnel, I'm wondering - any broken wrists in your past ?
I was in my doctors office recently for a check up. He spent five minutes checking me out and 30 minute on his computer.
8
I read this article with acute interest as a person who has worked in the tech industry for many years. What you have is a common problem found in every integrated ERP system. They are all cumbersome, difficult to customize, inefficient, and usually are filled with flawed data because they take time away from more important things to provide some administrator and senior executives with fancy dashboards showing how great everything is running. They add no value to patient outcomes but provide a convenient cover in case someone dies negligently to show that the boxes were all checked and procedures followed. A bean counters dream.
9
What about the GREED of the doctors who cram too many patients into too little time so they can make even more money and invariably treat the patient’s wasted time when the doctor is very late for an appointment, as unimportant.
1
Except that many doctors are now employees who are basically told how may patients they must see in order to keep their jobs. Why don't they refuse? Well, I suppose they could, but they would have about as much success as a McDonalds worker would who refused to make his daily quota of hamburgers.
4
GREED? are you kidding? Is that a joke. We are lucky if we are even paid! Ha! Greed? I know doctors and other practitioners who work more than one job just to pay the bills. Give me a break. Your comment is unresearched.
4
EHR's are awful because they were created to track information used to squeeze more money out of third party payers - not to improve patient care. Their inability to communicate with each other was caused directly by a colossal failure of the federal government to enforce uniform standards and by the IT vendors whose unquenchable thirst for profits is typical of our balkanized, unjust, and irrational health care delivery system.
14
We are seduced with technology, which will only increase. You better get used to it, like it or not, this is the future for humans.
1
I work with many doctors, I have to. I find this type of article (of which there are many, many, many) so irritating. The world has changed. We use EMRs now, before we used files, binder etc. Why does Dr. Verghese not recall that "a good craftsman never blames his tools"?
EMRs are not the problem (tho there are many subpar programs). They are a TOOL. And guidelines and checklists have been developed for SAFETY. There are many providers out there who learn once and never update or continue to learn or evolve. Healthcare is not static, it is ever changing. From what I read and what I see? Doctors and their professional organizations-lobbies (AMA, AAFP, etc) are a big reason why this has not changed. We are all members of the healthcare industrial complex and if things are going to change WE NEED TO LEAD IT OURSELVES. Complaining endlessly about EMRs is symptom, not the disease of profiting on the suffering of others. Let's face it, being a doctor or being a nurse practitioner (as I am) means I went to a lot of school, took and passed some big tests and met other criteria. I still put on my pants one leg at a time. I still get colds. Healthcare is a business, it costs money and there does need to be some accounting. Providers need to stop acting like billing and productivity are dirty activities. We need to stop acting like we work all alone without the help and collaboration of other providers. And we need to accept that maybe becoming a doctor does not mean becoming rich.
6
Well written and as you note efficiency comes with responsibility. I was taken back by your colleague's remedy for burnout - VC or startup involvement.. therein, the same capitalization of resources and diminution of the personal role.. thank you for the thughtful work.
Couldn't happen soon enough. So many doctors are just glorified plumbers who let their huge salaries go to their heads and convince themselves they are somehow special and entitled. All they care about is money. Replacing them with robots will make no difference.
1
The threat has already infected nurses.
2
I had a doctor tell me that she really wasn't a doctor anymore; she was now just a typist.
11
"Electronic health records and machine learning pose a threat to physicians’ clinical judgment — and their well-being."
Potentially, big data will give much better care at lower cost than arrogant and smug doctors. What's not to like?
1
Arrogant and smug patients?
Can we replace those with an AI also?
2
My doctor is so locked into his screen, if I had a heart attack and fell off the exam table he wouldn't notice till he heard the thud.......
19
After 35 years as a med onc, I have an opinion on this topic.
As noted I this article (and several I have written) the progress note in the EMR is mostly fantasy. It has become a competition to see who can cut and paste and auto fill the longest note- when in fact, all of us seeing the patient already have or should have reviewed the lab and imaging results. And for patient who have large volumes of data, re-posting ALL of it from day 1 just makes the note unwieldy and unreadable.
Frankly- all I want from any other treating physician is their impression and plan, but that is the piece given short shrift as it requires actual thought and typing.
I always refused to use the computer while in the exam or hospital room with the patient. It took me less time to document after I left the room and I felt better having a face to face and hands on encounter with my patient and accompanying family/friends. If I saw fewer patients, so be it. But most of my partners were hell bent on racking up as many $$$charges as possible- all confirmed with a monthly scoreboard of charges, many of them padded with Nurse Practitioner visits which they collected for.
It has become an ugly business with the EMR and administrators pushing only for increased billing and soon will be a complete loss of personal interest.
I guarantee that there is no EMR which can effectively record a cancer patient's 15 year complicated treatment history with CPT codes.
13
I work in hospital IT. A few years ago I was waiting for a meeting and picked up a Radiology journal. One of the articles was warning radiologists about a future where machine learning will make many of their jobs obsolete. After all, modern imaging systems save the images electronically now, not on film. In time, AI based systems will be trained to do what a radiologist does. The basic gist of the article was that if your job did not involve putting your hands on the patient, you will be replaced by future technology. Many highly skilled and paid jobs will be going away and we are not ready for that future which is getting closer.
3
I've tried, without success, to talk to professionals of all types -- those upper class types who think their "degrees" make them superior to the working classes -- and tell them that the future that is coming will obsolete their own professions JUST LIKE it obsoleted manufacturing workers. Some will be obsoleted by new technologies and AI -- but others will be obsoleted by the influx of H1Bs and lower paid foreign workers of all kinds. I already know ATTORNEYS who lost their jobs because they work they did was outsourced to Pakistan, where a lawyer makes $10K a year (and yes, they speak English). If you can outsource legal work, you can outsource quite a bit of medical work. Already, you can get medical "advice" on the internet for a modest fee! those doctors are still in the US, but they can easily be in China, India, Pakistan, Mexico. They might soon be AI programs with realistic animated software! So....white upper class professionals....do not get too complacent and do not assume that "you are not next" because YOU ARE NEXT.
1
This argument can apply to teachers too. Before the industrial age, technicians (or craftsmen, which is how they called that day) taught their knowledge to young apprentice. Skills were taught by individual rather than by school. Thus, this education in old day was much more personal and intimate (which is a neither good or bad thing). The population growth and the constant need to skill and educated labor due to the evolving society promotes institutionalized education.
What i try to say is
nothing can stand against the tide of technology revolution. Sure, there is some unpleasant things come with it, but it is too assertive to make a verdict. What we can only do is focusing on the positive side and try to find a balance in this mud water.
1
Having been thru a series of operations and procedures this Spring, I can say that the use of emr by all personnel including docs did not interfere with my care or their interaction with me. I just came from a medical visit this morning and the doc chatted me up while he typed in info. In addition he had my complete medical record sent via computer to him from my primary and it included all the heart tests from two weeks before.
It is an interesting system that involves participants of many levels of expertise that turns those with the greatest level of expertise into data entry clerks.
5
During several rounds of EHR implementation at one of the major hospital networks in NYC, I managed a team of computer technicians who assisted the doctors and nurses when they had problems with entering the data.
I was amazed by both the computer systems, staff interactions, and hospital hardware. How can anyone make any sort of rational decision when there are all sorts of beeps and buzzes going off all around?
What is the purpose of medical records? If each time a staff member "examines" a patient, s/he merely copies data from the previous exam, why not merely write "same, except . . .."? What is the benefit of converting check boxes to English language text? It certainly indicates nothing about the patient. But, as I observed, much of the data in the EHR had little to do with the patient either.
But even when the data were perfect, there was little use of it. Computers can do wonderous things with data, but there is little real time use of it. Yes, the EHR will warn a physician prescribing a drug that the patient is allergic to, or that interacts with another drug that the patient is taking BUT it will not warn of such simple things as dangerous trends. Blood pressure has been rising / dropping for days, or any other trend.
There was no use of data to suggest a diagnosis. And there is little interoperability. So why spend the money?
5
As this article alludes to, the adoption of Electronic Health Records was done to boost the economy and create jobs when it was mandated as part of a larger spending bill in 2009. Much like Cash for Clunkers. These systems are billing programs, and you will find few physicians who find that their productivity, work quality or career longevity have been enhanced by them.
4
Another case of not considering the ultimate consequences of unfettered, untried technology. We are trusting tech too much, and not protecting ourselves against the worst things that could happen. This will end up biting us all. It's about the money/profit, not about the welfare of people.
3
A major medical network in the SF Bay Area this experienced a major computer system outage. And the response from MDs and patients alike - they called local talk radio programs - was VERY POSITIVE. That's because the doctor was not lavishing all of his/her attention on the little screen and the patient was being addressed, examined, interacted with. For a change. Finally.
Seems that horrible UX is a huge and unforgivable problem with these systems. And, as others have noted, these systems help only the billing department and some office somewhere that collects the much loved and essential "data" that outclasses every other feature of life.
9
With a single code entered into the Medicare billing module, the friendship that had developed over two decades with my G.P was almost fractured. How it was described on his form Dr. S. could not recall, but he knew it was not the words that appeared on the Medicare Billing Statement, "Impaired thinking and developing a treatment plan"
On my first visit I noticed his award from the Republican Physicians Association on his wall, which turned out to be an opening for our discussions, and our developing mutual respect, He greeted me with a title that I never earned to show our equality, "Doctor Rodbell." One point that we did share was anger at the inclusion in ACA of "The annual wellness visit" This was passed with no publicity, breaching the confidentiality that is essential in the doctor -patient relationship. In the name of helping the Medicare patient, reports on his/her memory and sense of well being were to be monitored, which means sharing with bureaucracies without permission from the patient.
We treated it with the contempt it deserved, the danger of a return to a paternalism that had been abolished. Knowing my psychology background, he simply asked how I would do on the standard cognition test. But, he spent time with me that warranted payment for an extended consult, which he entered with no awareness of the offensive description.
We have talked this out, and I hope we are O.K. It's an illustration of the unintended consequences described here.
1
In my visits with my doctor at a huge HMO provider here in Cal, the Dr. is so busy typing out info on the huge computer set up in each exam room he barely looks in my direction. I feel rushed to get out of there so he can pound out the info and get on to the next patient. In an emergency room, the doctor never put a hand on me to examine me, did not even have a stethoscope on him; just a total reliance on lab tests and xrays and CT scans (all valuable tests) for the diagnosis. I welcome a scribe to be present, at least the doctor can focus on me and the scribe can document.
6
LISTENING involves more than hearing. A clinician, be it a physician, NP,PA,RN, needs to give the patient his or hers undevided attention, which means continuos eye contact, touching, feeling, palpating, percussing, smelling and the smallest clues can lead to accurate diagnosis and more focused ordering of confirmatory tests. Computer screens and key boards have a strong tendency to pull us away from LISTENING to the people who come to us for help. Listen to your Patient. You can enter the data when the Patient has told you his story.
8
One of the most significant predictors of patient well-being is the deep level of trust a patient feels toward their doctors. This intimate and central core of human relationships in medicine is developed through human contact such as touch, like a stethoscope placed on a patient's chest, a reassuring gentle grasp of the patient's hand by the doctor, the doctor emotionally touching the patient by looking into their eyes conveying unspoken, heartfelt concern, talking to people as both patient and friend, directly (without mediation), using a compassionate voice to bring news and comfort, nurturing what neuroscientists call "direct experience" which importantly, in a human way, gives us a felt sense that someone authentically cares, thinks about them in the context of both their expertise as well as their kinship as another human being, and and is paying attention to them with honesty and clarity.
Contrast this to when walk into a doctor's office and are met with someone looking down at a tablet - some gadget placed on our wrist or finger - never touched by another human being, little eye contact from another soul, never hearing the words, "how do you feel".
The mortality rate in the U.S. is rising - for many reasons. Perhaps one of the most insidious and difficult to detect, is that we are now treated by machines, like machines, instead of by human beings who we can trust - as opposed to boxes that simply compute. Humanity's health is at risk - not just a job description.
13
As a surgeon, I liked and embraced the electronic health record (EHR). Prior to EHR, I dictated all my patients’ clinic visits, operative notes, and hospital consultations, which were then transcribed by my assistant, edited by me, and then printed and placed in the patient’s paper chart. Now, the EHR “smart phrases” makes the execution and filing of a note far more efficient. My daily life no longer involves saying “The incision was clean, dry, and intact. There was no erythema or fluctuance.” over and over again.
Having EHR did not injure my humanity toward my patients, and in many cases, it improved my communication with a patient. I was careful to place my computer where the patient could see and share the screen to review imaging results, witness the details of a prescription, or contribute to a note to a collaborating physician.
I am attuned to Dr. Verghese’s concern about the future of clinical practice, as I see trainees losing sight of the doctor-patient interaction and focusing their learning on the electronic record and order entry. While this is now an integral part of medical training, it cannot replace the skills of an astute clinician. The established physicians need to adapt and embrace the benefits of EHR, while residents must take the time to learn bedside communication skills, examination and diagnosis. The cross generational physicians have something to teach and learn from one another.
7
Thank you for this article. I'm a nurse practitioner, and work with a team of MDs and nurses. We had a fairly simple EMR, but last year upgraded to the expensive Epic program. Now, we spend 2.5-3 hours computer time to 1 hour patient time. As others have mentioned, the software prioritizes billing over patient care. To read the narrative notes of the nurses, you scroll through all the lengthy billing data. Finding pertinent patient information, requires boring down several levels with click after click. It's tedious, it's frustrating, and ultimately demoralizing. We love patient care, but chaining us to our computers, is draining the energy that should be given to what we do best. Patient care.
24
Anna--I really hate the electron health records, and have refused to sign onto the ones offered by my caregivers. Nope. Not going to do that. Also, not going to spend my life looking down at a "smart phone."
4
How would the increasing and crushing documentation requirements imposed on medical providers be handled in the older, paper-based systems? Would the notes be longer with lots of the documentation that simply addresses the requirements and not tell the clinical story? I think so. The tools have changed along with the requirements.
The documentation tools used to be pens and dictation- but the requirements were less onerous. In addition to improving EMR workflow and interfaces, there needs to be reform of documentation requirements. This is complicated because it changes payment models.
1
I can't speak for other physicians but the notes I write on EHR are no longer than what I wrote when we still used paper and pen. The difference is that now those docs who foolishly thought they didn't have to write much (and thus painted a big target malpractice target on their back. My father who was a lawyer always said far more malpractice cases with lost based on lousy records than on lousy medicine practice). The EHR won't allow you to get away with that.
I retired from clinical teaching in the US after 35 years. I was the one full professor in our children's hospital who was "only" a general pediatrician. I loved my career at the beginning; I came to hate the changes wrought by the introduction of the electronic medial record (EMR). Residents would often take an entire history without looking at the patient, worse- without looking at the parent giving the history. All sorts of non-verbal clues were lost to the history taker. The parent interpreted the resident's focus the keyboard as a lack of interest.
Histories were often lifted wholesale from the previous note. Ridiculous errors were made by checking the wrong box: A girl was noted to have "testes descended bilaterally!"
It is classic that every generation of physicians laments the changes which occurred during his/her time in practice. The EMR is just another (the last?) nail in the coffin of what we used to call humane medical care.
21
How I wish I were your age, Dr Fischer! You saw the best days of medicine, while I am stuck in this grind for another few decades. I graduated med school in 2001, full of optimism and drive. I am a pediatric subspecialist who in my short career has already seen multiple reductions in appointment time, who is judged by a weekly productivity graph, and who was forced to attend customer service lectures in my hospital, for which consultants from hotel management were brought in to teach us how to be a nice person. I was sometimes envious of senior attending physicians in the past, due to their tremendous knowledge; now I am envious because you got out.
30
I wouldn't entirely knock the "customer service" aspect of things if I were you. I think a lot of lawsuits start with the snotty or impersonal or arrogant attitude of the doctor. You might be doing yourself a favor if you listened to what hotel managers have to say. People end up judging their healthcare providers much more on whether they were NICE rather than whether they diagnosed and treated accurately. You'll get sued if you think "customer service" is irrelevant. And don't be too nostalgic for some golden era where doctors were admired for their tremendous knowledge. There's truth to that, but the era when doctors were revered was also accompanied by paternalism, and the culture has simply changed. Again, like it or not but if you take the attitude that you have "tremendous knowledge" and the patient should just listen to you - you'll get sued.
The loud buzzing from this or that bit of electronic equipment has become a menace to patients in itself. A year ago, ear plugs notwithstanding, the swarm of audio assaults on the night before a surgery sent my blood pressure soaring to a distinctly pathological 170 over a number I've forgotten. This was partly the by-product of bad luck -- the only four-bedded room on the floor, next to a staircase and opposite the nurses's station. But even in average conditions the nerve-jangling assault from buzzers designed to arouse attention is bound to be a negative for rest and healing. Someone, invent an alternative please!
6
High paid CEO's and administrators see doctors as robots who make money. Healthcare changed when administrators started running the show and were only interested in the bottom line.
36
At a recent PCP visit the doctor asked me several questions before realizing she had the wrong record. I get why the problem happened because I worked for a teaching hospital when the EHS roll out came through. Having to console crying, confused and angry specialist who were spending less quality time with their patients gave a a perspective on this problem.
5
I am one of many physicians who did burn out and left medicine after realizing that the demand of entering minutia and shifting through non-sensical notes were putting me at risk of harming patients. When I left, I naively believed that the mess that EHRs had made of medicine was at worst the product of unintended consequences from well intentioned innovators, and that eventually EHRs would improve care. I know better now. Since transitioning to the biotech industry I've learned what happens to all of this data. It's de-identified and aggregated by insurers (Optum/United Healthcare as one example), and sold to Pharma and biotech companies as "real world data" a to provide benchmarks allowing them to compare safety and efficacy profiles of drugs in development. It is a huge industry with huge profits, but the folks supplying the raw data - the patients and the doctors doing the data entry, do not profit at all, and in fact provide this data unwittingly and for free. The real price price, however, is the erosion of the doctor patient relationship and the overall quality of care in the US.
46
BCO: your comment made me cry for us all. Docs, patients, healthcare providers. Business is not a model to be used in healing. Period.
7
Wow--this makes sense but I had never heard of it before. (DO physician 4 years out of residency.) Do you have any more information on this? Thank you!
Basically there's one real answer, and it's SINGLE PAYER NOW.
1
Doctors have become expendable. In 2010, a VA hospital CEO from Madison, WI during a talk on computerization, that I was required to attend, proudly proclaimed that computers will some day replace physicians. If payers, private and public, get their way then this is likely to be the end-game. I find that EHRs simply contain words pilled on ad nausea um, that don't really provide consistent useful information. I describe them with the expression, can't find the forest for the trees. For the for-profit health insurance and pharmaceutical cartels, patients are just sources of wealth. Due to so many aspects, our healthcare system is broken. Medicine under capitalism.
21
EHR is not the problem, they are just a means to data. The problem is the lack of focus on the individual person and what wellness means to the individual. Over prescribing tests and RX's is not patient wellness.
I encourage all to have a good DO who are trained to assess more of the whole/holistic patient. All patients also need to be their own advocates for care and what they truly want. Keeping a list of meds between doctors and repeating main elements of health history to initiate dialogue and improve effective treatment.
Likewise, the normal standard of care needs to be relaxed or expanded to allow the doctor patient team to decide the best treatment and path forward while still maintaining insurance coverage and without threat to medical license.
3
Sad to say, but DOs/osteopathic physicians are also made to use EHRs and are under the same time and billing constraints as their MD colleagues.
1
Most doctors would want to spend time treating their patients and not an electronic clinical record. Ideally, the clinical record informs a doctor for the subsequent interview, examination, and treatment of a patient. Too much time with an electronic record can interfere with the doctor-patient relationship; but so too can too little.
Now there are doctors who abdicate primary responsibility for writing their own notes to "scribes" who are present during the doctor's visit with a patient; and medical groups even have "coders" who review those notes to determine what types of service were given by a doctor. All of this is clearly intended to free up the doctor's time to see more patients (and to maximize insurance reimbursements). What can be lost in this process, however, is the doctor more fully taking ownership and time to reflect more meaningfully on the patient's visit in order to better develop and enhance the doctor-patient relationship.
3
Too many issues to address in this column. A few standouts; 1) When clinicians pad notes with incorrect data it is most definitely not the software's fault. 2) The good old days were not free of mistakes and oversights. 3) Older doctors often resist learning how to use the EHR, even struggling to place orders for the testing they need, prefering to make verbal requests of others. 4) Paper records are a nightmare. It is impossible to maintain a coherent picture of a patient's care and give broad access to that information with hundreds of pounds of paper records sitting in multiple locations. That said, the software will get better and machine-applied algorithms will first support, and then supplant, humans trying to do the same thing in their head. None of this is to deny the challenges that profit-based medicine pose, or the need to improve the patient exam and other interactions.
4
I am a physician. As soon as our hospital's EHR allows us to "close the encounter" with a particular patient, the hospital is able to instantly bill the insurance company for my services. That's the real reason for EHR--to provide an efficient and seamless method to bill for services.
Two generations ago, if you asked a physician to type a note, they would have given you a puzzled expression in return. Bit by bit, the administrators have pushed us now to become clerk/typists. We have gone along with it in the name of record clarity. But there is a price to pay for that enforced dependence on keyboards. I less like a clinician and more like a counter employee at a rental car agency every day.
None of my children have decided to go into the medical field. That's fine with me. It seems like a grim (and expensive) choice of professions.
26
During my last year of medical practice, I went to work for a community mental health center in Michigan, after closing my very successful private practice. In private practice, I had used pre-formatted initial evaluation forms and progress notes, spent a minimum of 20' with each patient F/U visit, and always looked directly at my patients. I saw 20 or more patients in a 9 hour day. At the mental health clinic, where I was required to use an electronic medical record, I saw 8 patients a day and was forced to turn my back on patients to access the desktop computer. So glad I'm retired. I love my laptop, but treating the computer, to the exclusion of the patient, is just bad medicine. E-medicine is over-hyped.
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Dr. Miklashek: the physicians I have seen in the last 7 years -- including nurse practitioners -- have spent nearly 100% of my visit staring/typing on a screen -- sometimes a laptop (yes, with their back facing me) and sometimes a newer iPad tablet on which they "swipe" rather than type -- but the same thing, basically concentrating intently on a SCREEN and never really looking at me, or talking to me except to ask yes or no questions. EVERYTHING is centered on tests and blood work, and the results of tests and blood work. No doctor or nurse-practitioner makes eye-to eye contact anymore! It's awful and very dehumanizing. And we can thank Obamacare for much of this, as it made electronic records MANDATORY.
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Verghese wisely calls out the degradation of care that has become the unintended consequence of the EHR. He doesn’t emphasize how much an assembly line pressure to cut time spent with patients adds to the mess. Satisfying the digital record not only serves as cover for Risk Management concerns, best billable service,it also becomes an incentive for glib fraud in recording a physical exam.
But why is this short cutting now so prominent? Why are primary care MDs seeing patients for 8 minutes or relying more & more on nurse practitioners to take a history? How did the Md-patient encounter get so cheapened?
It is crucial to understand that sound care requires understanding a patient; this is not ‘bedside manner or canned empathic phrases. It demand some time, curiosity and meticulous attention. Small details matter.
Medical education must join with seasoned attending like Verghese and push back. Accommodation to the new production demands of medical care has too long been rationalized as part of being realistic. It is also hard to be a good doctor and also rebel against systemic distortions of practice. The greatest distortion is the accelerating panic at covering costs.
Only Medicare for All can reduce that malignant trend.
Verghese should include the financing of care in his analysis.
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Unfortunately, Medicare mandates an EHR, with all the accompanying problems. So Medicare for All will not resolve that problem. I am a dinosaur in a group pediatrics office, and we still use (gasp) paper charts and love it.
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I have some bad news for you -- Medicare is not only as BAD, it's worse. It reimburses so little, doctors feel intense pressure to do everything electronically, make visits very short and talk/touch patients as little as possible. "Medicare For All" may be good or not good, but it will NOT solve THIS problem.
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Machines taking over employment for "industrial" jobs, is ok, because it is more efficient (i.e.; it increases the profit margin for the owner of the company). Machines taking over jobs we historically called "professions", not so much.
Don't see any difference?
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I have seen my newest doctor four or five times. She enters information on the computer, occasionally looks at me, but mostly she delivers speeches. During my 40-minute annual exam, she did not touch me even once. She read through the results of tests without verifying a thing. In fact, she does not provide health care at all. She is not interested in my medical records. She does not review my history.
When I took concerns about treatment to a specialist, he did not look at my history either. He also delivered a set piece. He was there to encourage me to take the medication my primary wanted me to take.
Many doctors in my county will not accept me as a patient because I am over 60, and they do not want too many Medicare or soon-to-be-Medicare patients. There is less money serving Medicare patients. If doctors want to care about people's health, perhaps behaving like a person themselves would help? Perhaps going into the most obvious growing specialty, geriatrics? But no, they do not do that. They want income.
I would be better served by the new computer-diagnostic systems currently being developed. They would not spent half of an exam explaining paperwork or statistics I already know, but they might at least take advantage of the records they and others have stored. They might see me as a person with a long life and a growing list of medical concerns.
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My records from a specialist included referencing tests no one had completed and information that was incorrect. Despite filling out forms in the waiting room, I have never found the information on those forms make their way . . . anywhere. I have had to correct my records repeatedly.
I was sent home with post-surgical instructions for the wrong surgery, and my paperwork showed the wrong surgery. When I pointed out the error, the surgeon just laughed and failed to make a correction.
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They won’t “see” you at all. That’s Dr. Vergese’s point. They take “you” out of the equation. I refuse to change a patient centered approach to satisfy our administration but am at close of my career. I can afford to do this by jotting down relevant notes during a visit and writing actual notes hours later for unbelievable amounts of time compared to just dictating and correcting those inevitable dictation errors.
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Beautifully written. And on target. My partner and I have wandered through a three-plus year ordeal of dealing with a head injury produced seizure disorder. So we've seen lots of the medical world. Ended up in the ER last week because suddenly he could not stand up or talk properly. The ER doc, a youngish woman with a luxuriant pony tail of curling dark hair told me, "I read through his history while I was waiting on the MRI, he's not having a stroke, I think its a post ictal state. Let's get a blood level on his seizure medication, okay?"
In the ER setting I had been less than eloquent in my relation of the long story of his "illness" to them. He could not talk at that moment, and the medical records evidently helped fill in the gaps. I did feel seen.
Final note--patients should have opportunity to see, read and if necessary correct, their medical records. Errors are more common than we think and they influence not only diagnostics, but attitudes and actual care.
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As a senior academic physician (anesthesiologist) with aging parents who are spending increasing portions of their lives interacting with clinicians, Dr. Verghese's diagnosis resonates with me. What used to be in every progress note, a succinct patient-centered narrative, is now difficult to find in the EHR. A colleagues calls this "data rich and information poor." More and more of my job is spent accommodating to the needs and limitations of the EHR--I work for it more than it helps me.
My father, frail and for most of the last decade under treatment for cancer at another academic center, has had his care transferred to two new primary care physicians and three new oncologists during that span. These disruptions cause him great distress.
A common theme, not mentioned by Dr. Verghese, is that our healthcare systems have been captured by "leaders" who may have undergone clinical training, but who increasingly also have MBAs and think accordingly. The ethos of these leaders echoes that of other big American businesses, with a focus on easily measurable outcomes: efficiency, standardized documentation, growth, and optimal billing. Appearances and process win out over immeasurable qualities that patients and clinicians value more: trust, caring interactions, and outcomes that align with patients' goals.
We physicians are privileged to help those in need. Reminding ourselves of this helps avoid burnout and resist the growing corporate ethos.
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As an anesthesiologist for more than 30 years, I have seen the implosion of good medical care as internist and others face increasing pressure to see more and more patients in less and less time. Reimbursement for physicians has fallen dramatically as "health care" costs skyrocket.
I have a feeling that my senator and his family do not find their physician "rushed" to get to the next patient when they need medical care.
Hospital administrators, who's salaries are often much higher than physicians, consider physicians just replaceable units, and patients are "customers". The emphasis is on greater and greater profit.
Private practice physicians are being more and more hired by medical systems as they are not able to survive with falling reimbursements.
The primary driver of EMRs seem to be to optimize billing and profit, and avoid litigation.
In the OR paperwork, the vast majority of it duplicative, is "required" before an operation can take place. On some pieces of paper my signature is required in 3-4 places. There are checklists to insure other checklists have been completed.
I do not have an answer, except to get rid of layers of unnecessary bureaucracy that has permeated health care. I doubt single payer health care will help much. But whatever happens I want to be assured that me and my family will get the same level of care my senator has.
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Why was and is it not possible to have programmers follow around practicing physicians and modify these EHRs to make them facilitate clinical input and patient management rather than solely facilitate billing?
Part of the great misfortune that has occurred is that when physicians have been involved in EHR mandates they have never been practicing physicians but rather MD/MBAs?
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I am a physician, and my patients seem to think that I am a good one.
I cannot get out of this profession fast enough, and the electronic medical record (of which I have used a variety over the years) is one of the main reasons why.
Burned out? I'm crispy. I'd have a few more years in me if I could go back to writing on index cards.
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I have been practicing physician in the emergency room for many years. The electronic medical record ,the way it is designed ,was for billing. There are other medical record systems that are more patient oriented. The problem is there is no place for the “person” in the algorithm. Also, there is no room for the placebo effect which can take place when there is good doctor patient communication. According to many studies this accounts for approximately 30% benefit. We are missing lots of ”healing” by not paying attention to this....In some facilities, emergency physicians are using scribes to help overcome this problem.
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Ah yes! The good old days. A physician’s great bedside manner was required, but patients had no idea how to judge the clinical skill set. Fragmentation was unheard of, because most had just one doctor. That was possible because, in reality, few treatments were effective but could be known by most physicians. People paid with cash (or maybe chickens) for the diagnosis and treatment plan making extensive note taking irrelevant. Flash forward to today. There are a dizzying number of tests, treatments, guidelines as well as evidence of which treatment plans and which sequence produce the best outcomes. We know this is beyond the capacity of any one physician to manage, but we have not figured out how to rein in our fragmentation, reduce duplication of information or provide care based on patient preferences. Our payment systems are based on the procedure and the word. Why are we surprised at the explosion in volume of both. Other industries have figured out how to get the technology to work for them. Health systems continue to misuse EMRs to delegate work to physicians.
Medicine is still behind the curve. It needs to figure out how to capture the power of the EMR to make patient experiences and treatment better. A good share of that will only come when new approaches to payment, sharing of information and accountability allow physicians and other healthcare workers to have the EMR work for them, rather than the other way around. In the meantime, fix it and stop whining.
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The problem is not the Electronic Medical Record, which I had to endure at the end of my career, spending more time documenting than with patients. The problem is health care as profit motive.
Doctors see their time as billable units. If you slow down the process of patient numbers/contacts, you slow down your billing. It's quite possible to take notes and do your inputting of information AFTER you see the patient.
The issue really is also two-fold. Oldsters are just slow at computer work, due to vision issues, typing speed. Younger docs speed through this.
The second issue is that electronic records are imperative for patient safety and medical efficiency. The names of drugs alone are reason for this! One's history of procedures, medications needs to be accessed quickly by specialists, emergency care-givers, to avoid mistakes and unnecessary duplication. This should take minutes, not hours, which was the case not long ago.
I do feel some programs, like the one I used, are unwieldy and intrusive. Information for your personal physician should be separate from the basics needed by a secondary care-giver. In that case, the shared record should be "just the facts, ma'm."
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Yes yes yes. As a physician (and patient - a country we all will become citizens of - ) the computers their demands yes the requirements of our billing notes set by CMS and others in far away Capital’s are impeding the direct doctor patient interaction that was the hallmark of care in a not distant era. Yes we need more better and reliable data but the servant - feeding the EHR - has become the master. And certainly the physicians nurses house staff I see are suffering because of it. Call it burnout or depression or slow motion grief at the loss of what we know we are called to do. We really need to do far better and soon.
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My husband and many of our friends works in the healthcare industry both in hospitals and in private clinics. The stories I hear make me doubt the efficiency of the medical system in this country. There are protocols in place to do every conceivable test on patients to make sure that nothing is missed driving up everyone's costs. Unfortunately, all of these things and the excessive documenting of records have resulted because America is just such a sue happy country. Doctors and hospitals feel that they have to cover themselves and if they can say we did *everything* they could, then they'd be more protected.
All of this has led to doctors not really diagnosing anyone, they wait on lab results, CT scans, and a myriad of other things to come down before they might even see the patient. At this stage of the game, I'd rather rely on AI to diagnose me than a human doctor since they're not providing anything else. If the medical profession wants to not get displaced, they really need to think about how to re-vamp how doctors interact with patients and the country needs to not sue so much but I'm not sure how we would bring that change about.
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Physicians who drop out will find the same thing in many other fields. Systems promoted as a boon to practitioners (of all kinds -- doctors, teachers, judges, etc.) to achieve increased accuracy and efficiency almost always evolve, and rather quickly, into systems whose main function is data collection, the products of which are then used by management for various purposes unrelated to accuracy and efficiency. Systems are not designed with needs of users in mind; they are designed with the wants of management in mind. And when you call them on it, you are branded as an anti-progress dinosaur. The author is describing the near future of almost all white collar work, not just medicine.
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Take heart, there are other voices in the wilderness increasing in strength shedding light on the fallacies and harm that result from riding this train. I'm working my way through a recent book by Jerry Muller, The "Tyranny of Metrics" and it is a good scholarly critique on this widespread problem. He calls it metric fixation.
Thank you. I've ordered the book and look forward to working my way through it, too.
"I hold out hope that artificial intelligence and machine-learning algorithms will transform our experience"
I did Infectious Diseases for 45 years; saw a lot. and actually interviewed and examined my patients. One day my first two patients had bedsores; Th first was a bilateral amputee.The second had been paralyzed for 3 years Nowhere were these causes for bedsores recorded.
The real purpose of the EHRs is to provide the feedstock for "mass data", the Artificial Intelligence to which our author aspires and about which he properly worries about the inputs.
Epic is the dominant EHR and allows the rollover of all of the notes so as to include information that allows billing for the highest levels. I can tell you that the original histories and physicals were entered by medical students and are still being rolled forward; that the information is unreadable. I've seen charts where the records describe different patients.
The "healthe care planners" fantasize using computers to simulate the human brain function so as to cut physicians and support staff out of the cost structure-you know-gather all of the records of billions of patient encounters and so construct the judgement that "good" physicians would have make.
Right now these beancounters spend billions the false grounds that it is better to measure something than to measure nothing. But they won't be able to use the junk entered into the current EHR without committing medical malpractice. as though they cared.
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Doctors want to be more like nurses. The focus of nursing is care. Incredible, considering that nurses outnumber doctors by about four to one.
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"Doctors want to be more like nurses."
What?!? Seriously. No they don't. At all.
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This article is deep in wisdom. It offers an astute diagnosis and accounting of the symptoms modern medicine suffers from: excessive mouse clicks, little to no eye contact, and narrowly viewing patients as an (electronic) diagnosis rather than a vulnerable human being. The cure is simple, yet challenging in time-starved medical settings; make a genuine human connection with every patient. It is more than being nice. It is optimal health care. Patients who feel "seen" are more compliant, suffer less, and have better outcomes across the board. Plus, human connection is what we all need when we are pulled into the world of illness.
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In this age of massive pharma, mega insurance and corporatization of care, we might tend to forget one small detail: at the end of the day when all is said and done, it is the doctor who has to make the decision about me. That’s who I go to see. I really don’t care about all the gadgets and gizmos when something hurts - I look to my doc. She/he is the center of the system. Ultimately it is the doctor who is accountable. We better pay (attention to) the piper.
4
From the beginning of my career in the 1970s I watched and took part in the "computerization" of medical care. Every few years there was a new "rollout" of the latest technology, which usually initially went badly for a little while, and then we got used to it. Each time we adapted, we believed the promises of the vendors and tried to work with them, but mostly we got explanations of why "we're not quite there yet...". And each time we adapted, we were pulled a little further away from where we started, as young, smart, incredibly hard working, focused clinicians. From a perspective of almost 40 years, it is obvious now that two things always persisted: the faith that the next iteration of the technology would be the one that finally pulls it all together and delivers us into the promised land of computers actually being helpful, and the ever recurring "new deployment" of the next technology that once again just missed the mark and just drew us further away from the bedside. Doctors are very susceptible to the idea that if we just try harder and work longer we can make this work, and yet it never quite does. The medical record tries to simultaneously serve too many purposes - legal, financial, practical, regulatory, etc. - and thus fails to serve any of them well. Or worse, its evolution is distorted to best serve those functions associated with money and defending. This is a recipe for burnout for the operators, who have literally become data entry clerks.
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All those who work in the medical care professions are experiencing a version of the phenomenon. It is not the care given but the care given to paperwork that rules the relationship with patients and clients. A speech-language pathologist by profession I retired early, let all my licensure lapse, and gave up practicing altogether not because of clients or caseload but because of the ever increasing paperwork. From the inside out I know how this focus on documentation dilutes the effectiveness of caregivers.
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Having practiced medicine in the analog and electronic ages, I find that the EHR systems I have used largely fail to improve the provision of patient-centered care. The fault lies with primary motivation for their design - to maximize billing. To a large extent, physicians, nurses and other providers have become data entry clerks for hospital systems and insurers. These systems demand hugely redundant and medically useless data input, which forms a shifting battleground between the institutions doing billing vs those that are paying. At the user level, the systems are universally unfriendly with myriad fields of 5-point font and non-intuitive GUIs and workflows. The result is medical “charts” so packed with irrelevant information that it can be very hard to figure out what’s actually going on with the patient. This is a sad missed opportunity because the power to make all important clinical data available on one screen, to reconcile meds and avoid prescribing errors, and to harness the web and possibly AI for expedited and accurate differential diagnosis and treatment algorithms is fantastic. Too bad that Steve Jobs didn’t get around to working on this before his untimely and possibly preventable death.
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Nowhere is this more obvious than at the VA.
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My primary care physisian is a highly-rated, experienced doctor in her early 60's. She is not a "computer-person," but nevertheless is now required to take notes on a laptop while she talks to me. She always has difficulty doing this, whether due to operator error, software bugs, or both. During my most recent appointment with her I simply stopped talking until she looked directly at me. It's stressful and frustrating for both of us.
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"Required"? Required by whom? As far as I'm aware there is no legal or ethical requirement why someone can't take notes on paper while seeing a patient and then entering the information into the EHR after the visit is over. The only reason doctors don't do this is for reasons of making money.
But that's not entirely fair, Steve. Of course yes she could write up the notes later. And that's fine if we expect doctors to simply work around the clock. But then let's not complain if they make good money, or if they get burned out because they have no personal life or their families never see them.
Profits have been put well ahead of patient well being and healthcare provider relationships. The pressure hospital groups and other entities place on doctors and nurses to be "efficient" (read see more patients and make more money) coupled with all of the technology that is suppose to help them and you have recipe for disaster.
As long as profit owns the healthcare industry, we will not see the excellent doctor/patient relationships we had decades ago.
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I see it somewhat different.
All the time my PCP spends on inputting into the laptop he carries with him could be used to examine another patient and, thus, increase billing.
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" .. As long as profit owns the healthcare industry .."
That include "people's presidents" who get $400,000 a speech? Them's good profit, right?
My M.D. uses a "medical scribe," a pre-med who makes $12/hour, keyboarding his comments, into a laptop. My M.D. doesn't whine about another crisis started in 2009, he just finds a solution.
Finally, I always double-check the scribe's work, which I get a copy of. Expecting others to be as concerned about your health, as you are, that is just absurd and bizarre. You are the best doctor for you, because you care about you, the most. Really. Not kidding.
My GP, whom I have been seeing for many years, and will continue to see, is heavily invested (financially and functionally) in electronic health records. Indeed, he is sometimes criticized on doctor-rating websites for spending more time reading and inputting data into his computer than interacting with his actual patients.
Despite his great attention to detail, for years he (and his nurses) have failed to enter into his/my database the fact that I had a prostate cancer operation 4 years ago and that I am on a protocol for 6-month follow-up PSA testing. I recently made a point of strongly communicating to my doc and his nurses that this critical information should be in my file, so they finally added it.
I have great sympathy for my doc because I am on Medicare and the payments he receives for meeting/treating me are a pittance. A large proportion of my doc's patients are on Medicare, so to survive financially he must move as many patients as possible through his office as quickly as possible.
I am a well-educated and medically-savvy person, and I know the time pressures my doc faces, so I simply make sure I don't leave the examining room before my issues and concerns have been addressed to my satisfaction. I am therefore happy that my doc is relying on electronic health records, and in the future may rely on machine learning, to assist in forming his clinical judgments. Differential diagnosis is as much art as science, so if machine learning can help, that's great.
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I'm a millennial who's old enough to remember paper carbon-copy orders that we, as students in our precynical and cynical years, would literally file at the nurses' station, yet young enough to have used EHRs since my intern year. Despite their shortcomings, I still find that EHRs provide a great boon to the overall workflow of medicine. An EHR progress note full of pre-populated text is absolutely dreadful to read. But to paraphrase a mentor of mine, "it's like you guys were given a Cadillac and you don't know how to use it." I type my notes as if I'm hand-writing it, i.e., I make sure to read everything if I'm going to be using dot phrases. It's my responsibility to make sure what's in my note is accurate, not a program's.
EHRs can be programmed to shame those who copy-paste to oblivion: a pasted text comes up with a different background color on a new note. All can see the writer copied it.
Upcoding is easier with EHRs, and thus more annoying to providers. But upcoding is not inherent to EHRs. That's on your boss and the payor.
The electronic interoperability (or lack thereof) between hospitals for medical records is dependent on ease of consent, and the hospitals' lawyers and their interpretation of privacy laws. The function is there, and I have used it on the rare occasion when it works.
Didn't want to end up sounding like a PR person for EHRs, but I think the article's critique could have been more precisely targeted at issues with billing and how doctors are paid.
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I'm a baby-boomer MD nearing retirement and I thank you for your thoughtful comments. I too have used both paper and electronic medical records and would add a few observations about our current EHRs:
1. It's nice to be able to READ the record. Too bad so much of it is useless garbage.
2. The primary goal of most EHR's is to increase reimbursement.
3. The secondary goal is compliance with the myriad of regulations
4. Patient care is way down at the bottom.
5. I write my electronic notes the way I wrote my paper notes: in my own voice--no dot phrases--including only what I actually do in the interaction (I stopped doing "complete 14 point review of systems" for routine follow-up visits decades ago; I am not going to start doing them now and I am certainly not going to lie about doing them.
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Your comment about being given a Cadillac (let's substitute Lexus hybrid) and not knowing how to use it is absolutely correct. EHRs are very useful in several ways: one can actually read the clinical note; prescriptions can be saved and templated so they don't have to be rewritten constantly, and written one time accurately they stay accurate; prescriptions can be sent electronically (the MAJOR EHR benefit in my opinion); flow sheets of vital signs from previous visits can be viewed. I think the clinical note is too busy and I always try to make it as simple as possible. The clinical note can be printed out and I often hand them to patients for various reasons and tell them to edit anything they feel is inaccurate.
1
The opportunities you note to improve EHRs with a variety of safeguards. are all true -and could be beneficial however, there is no incentive to do so (and there won't be) --this is the point. It's all at "what the market will bear" and this is at the cost of what almost all folks say is a basic quality of healthcare: the time and focus to look and listen.
As usual, magnificent and poignant prose. I hope, someday, we find our way back to the patient and art of medicine. Thank you for continuing to call this out. Lisa Fitzpatrick, MD
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