40+ years as a physician, 35 of them involved with computerized medical information systems, a 3-year informatics fellowship at CDC, and even some paid consulting have perhaps given me some perspective on this issue. I believe the bottom line is this: all but one of the prevalent EMRs are rejiggered financial payment systems that have not outgrown their original purpose and thus subjugate clinical goals to monetary ones. The one exception is the Veterans Administration VistA system that was built from the ground up since the late '70s to fulfill the needs of providers and patients. Under intense attack by the commercial vendors who have long wanted that market, it still survives - barely - due to the fierce advocacy of its users. What's needed now is for those studies in Annals and Health Affairs to publicize exactly which EMRs were the worst and the less bad, and let us all reach our own conclusions as to which ought to be permitted to continue in use. Yes, I say 'permitted' because I too believe that these tools, just like surgical robots or MRI machines, must be under the jurisdiction of the FDA and must be shown to be safe and effective before being put into use.
4
A large factor in medicine has always been the hands-on by the doctor to their patient. To listen to their hearts, feel the places that hurt, to gain an understanding by using another human sense - touching.
I have noticed over the last several years, that doctors touch their computers, listening and typing in information, and they make occasional eye contact. What they don't do is an hands-on medicine. Which is not only an important deductive tool for the doctor, but a comfort to the truly ill. One human touching another to gain understanding and provide comfort.
It's fallen by the wayside to computers.
5
What can we tell about Nurses wasting time away from patients ? In Brazil we have some good E.M.R solutions, but they need increase new resources to accept Voice and Face recognition to help input information on systems.
Another very important question is about E.M.R. processes setup. We can have two hospitals using a same solution but with very diferent results.
If you don't have a good multiprofessional informatic team to setup your system, you can have a intergalactic E.M.R. solution and you'll have your phisicians and nurses suffering to work.
We don't need to return to Stone Age, information available and online about patients save lives, but we need to solve the binomial machine-human interaction.
We hope don't depend only on Robots !!!
1
Continued from previous
I spend a considerable amount of time arguing against the double documentation brought on by regulation, liability and quality initiatives. Not to mention the documentation requested by physicians, nurses, administration, infection control, etc... just because they think it ought to be kept someplace else in the EMR.
My point being that I hear your pain and share it but the truth is that for very much of this we are our own worst enemies. We complain about the labor then request and fight for more labor to be involved.
As a shameless plug for my coworkers out there in the clinical informatics field I'd also suggest getting with your clinical systems personnel and spending some time and effort in learning and utilizing the many tools in your EMR that will save you considerable amounts of time. Things like auto texts, voice recognition, macros, and templates can give you valuable time back, but you have to be willing to put forth the time and effort to learn it and utilize it. If your facility utilizes nurses in this role you’ll likely find a knowing ear and a knowledgeable champion.
2
With all due respect, you are wrong that it should be considered a physician's duty to perform the clerical tasks mentioned.
NO ONE would demand that the surgeon order her own instruments, much less autoclave them and set them up prior to each case.
There is a simple solution. "Give to Caesar what is Caesar's". Scribes are typically pre-med students who want to learn about heathcare and form relationships. They typically take a lower than expected wage in return. They also typically essentially pay for themselves by increasing productivity, not to mention, increasing morale.
If only those who could implement this basic solution, such as yourself, would listen.
Why ask the most trained and specialized member of the patient care team to literally waste time that could be spent with patients by asking they perform non patient care tasks?
1
In this case, I must agree with Dr. Alvarado. The desire to have physicians perform all their clerical functions looks good in ideology, but in practice is just not feasible. Dr. Alvarado is correct when he says that scribes exist for a reason.
My neighbor is a long-time hand surgeon who has complained heavily about EMR ruining his ability to tend to patients. He has commented that not even 10 years ago, he could see upwards of 60 patients in a 7-5 clinical work day, then perform 20-30 surgeries the following day and keep that up for weeks at a time. With the EMR system his hospital employs. He is down to 35 per day in clinic (if he is lucky), and 10-15 surgeries per day. All because he must do all the clerical work that EMR advocates say he should be doing.
Dr. Alvarado nails it when he says: “Why ask the most trained and specialized member of the patient care team to literally waste time that could be spent with patients by asking them to perform non-patient care [oriented] tasks.” This is clearly evident in my neighbor’s case. The burdens his EMR gives him means he sees 2,600 patients less per year and performs 1,000 less surgeries.
So, in the end, who are the real victims? Not the physicians. It’s the patients. This is why delegating responsibilities to clerics, scribes, nurses, and whomever else is so important in providing the best care for the most amount of people. EMR doesn’t have to be our enemy, but currently it is not our friend.
1
Just for another perspective here.
I am the Clinical Systems Supervisor of an approximately 500 bed hospital running an enterprise EMR from a major company. I am not exactly just a voice from the peanut gallery.
While I certainly agree that the current EMRs are labor intensive for all those involved I'd like to point out that there really isn't necessarily an increased effort going into it. The effort simply has been placed back on the originator. In the paper days, the physician would come through the unit, make their rounds, write their orders and their notes and leave (I was around when they actually required a nurse to round with them while they dictated the orders to them to signed at a later date). After that a multitude of individuals were involved in those orders being transcribed, typed, recorded, parsed, double checked, approved, verified, communicated and finally performed. Today the EMR takes over more than half of those tasks and requires the physician to be responsible for a great part of what is left over. You have to dictate and double-check your own H&P, daily, and discharge notes now (You really should read your notes). Your orders are entered directly by you into the system (errors and all, and yes you make many of these) so that we cut down the number of oral and written transcriptions errors.
Continued below
1
In this case, I must agree with Dr. Alvarado on this case. The desire to have physicians perform all their clerical functions looks good in ideology, but in practice is just not feasible. Dr. Alvarado is correct when he says that scribes exist for a reason. My neighbor is a long-time hand surgeon who has complained heavily about EMR ruining his ability to tend to patients. He has commented that not even 10 years ago, he could see upwards of 60 patients in a 7-5 clinical work day, then perform 20-30 surgeries the following day and keep that up for weeks at a time. With the EMR system his hospital employs. He is down to 35 per day in clinic (if he is lucky), and 10-15 surgeries per day.
Dr. Alvarado nails it when he says: “Why ask the most trained and specialized member of the patient care team to literally waste time performing non-patient care [oriented] tasks.” This is clearly evident in my neighbor’s case. The burdens his EMR give him means he sees 2,600 patients less per year and performs 1,000 less surgeries. Wouldn’t this be considered a type of negligence? A physician has a duty to help the patient, but because EMR limits his ability to help patients, patients are being harmed. This breach of duty is occurring because the physician is forced to waste precious time on tedious EMR systems when it should be used to help more people.
So, in the end with all things considered, who are the real victims? Not the physicians. It’s the patients.
Ever notice how to be a physician leader it is requisite to have a MBA? It makes some sense given that financial issues have assumed the omnipresent lead in medical decision making. This is not entirely inappropriate given the financial ranking of the U.S. (first in cost, first in medically induced bankruptcy, middling in quality.) Most of us agree with the quadruple aims of CMS, (decrease cost, improve quality of physician / patient interactions, improve the health of our entire population, and improve the lives of physicians - particularly primary care physicians who are essential to achieving the first of the three aims.) These are appropriate, worthy goals and they call for a nobler influence in the practice of medicine than is promoted by receiving an MBA.
Does it not make sense that the administrative leadership in medical systems be certified as having meaningful exposure to these nobler values, at a granular experiential level. Administrative leaders should be required to serve externships in which they are required to work with EMRs, to tell dad it is time to stop driving, and to tell mom she is going to die, and to be exposed to the ludicrous financial deviltry of the pharmaceutical industry. Let our administrative leaders get the feel of our reality.
1
The EMR is, to paraphrase the bard, a document full of sound and fury signifying nothing. The current iteration of the EMR is a document for billing and not for communication. Most of what is in every physician's medical record these days (including mine) is total drivel. The records are lengthy, unreadable, unwieldy, and full of useless info. The last commenter placed the onus on the illiteracy of the physicians. Sorry, she is absolutely wrong, The world of IT does not really understand what the medical record can and should communicate. Most of the stuff in the charts should be hidden in the background; the endless repetitiveness of the chart reflects the world of IT not understanding what doctors really do and what info we really need. I am 70 yrs old and have been practicing neurology for 40 yrs...my kids and grand kids have taught me how to be computer literate. I think it is time for the IT world to rethink what they have foisted upon the doctors.....after all, they too will be patients one day.
3
I work in healthcare IT and we have never been involved in determining what items go in a medical record.
Hello! I have been in programming. I am in the peanut gallery firmly, except as a programmer and a patient. I just want to say that the technologies and software available have been increasing fast over the past few decades. The software will get better and better. Just right now, it is a pretty bad mess, and primitive.
I have an IT implementation background. I work with physicians, and I love them dearly. That said, many are functionally illiterate when it comes to using IT, period--well beyond the scope of EMRs. While EMRs absolutely must be improved, the flip side is that many physicians--regardless of age or stage of practice--must arrive at a basic level of IT fluency. This is the expectation of specialists in all sectors, and doctors should not be exempt from higher standards.
2
The EHR should be a tool for us to use to do our work efficiently and well. When I cook, I expect my household appliances to work when I turn them on. If they break, I call a repair person to fix them; I would be outraged if the manufacturer expected me to fix them myself. If an appliance's reviews indicate that it is so complicated to use that it's a drag on efficiency, I don't buy it.
Why would we not expect the same standards to apply to the technology we use at work? I understand that healthcare systems would like to make us all into our own IT trouble-shooters; but that's a position that serves the enterprise, not the needs of the patient or the clinician. We have become all about serving the needs of the enterprise at the expanse of our customers, and our workers.
3
I retired two years earlier than planned as an Occupational Therapist/CHT due to EMR and having to constantly fight with insurance companies for visits.Almost none of my former coworkers enjoy coming to work anymore.
4
The problem at its root is simple. We are all too beaten down to summon the courage to say no.
Just say no.
5
I am a medical oncologist in private practice.
The author is right--each and every new regulation; quality or safety initiative; or billing/coding change filters down to a new box. Or two. Or 12 to click with each encounter. I've even questioned in my large group practice why it is that proposed change "x" would necessarily need to be another burden placed on doctors to document even more in the EMR. Could that task be done by somebody else? The response from administrators is ALWAYS the same: "Well....uh....it's just one more click. It's not going to take THAT much more time. Deal with it." But the problem is precisely that it's death by 1,000 cuts. We as doctors never draw a line in the sand because we feel powerless to do so.
I kinda get the feeling sometimes that more work on my end makes somebody else's job easier (biller/coder, admin, QC, etc.). When shouldn't it be the other way around? Who's really in charge here? I'm the one with the license.
That's why I like Dr. Ofri's suggestion that frame the EMR overdocumentation issue as a patient safety one. And there should absolutely be big $$$$ penalties for forcing time away from patients. The only way to end the burden of overdocumentation is to hit the pocketbook.
6
Why is it when I order something from Amazon it takes a handful of clicks but it takes no less than 10 clicks for me to order a simple medication for a patIent? The design and user interface of the EHR is a hindrance rather than a strength. Until that is solved we will remain slaves to the EHR one added click at a time.
5
Your not ordering books, you're ordering a complicated medication\procedure\treatment. You can't expect the two to require the same level of complication.
That being said get with your local IT staff that deal with the clinical systems. You may be able to save your frequent orders as a favorite with many of those order details already pre-filled, saving you valuable time.
Excellent article! EMR and other hoop jumping and box checking is killing the art and joy of medicine, as well as hurting patient care. Even as a radiologist - my eyes used to be on my patient (the images) the entire time I was evaluating a study. Now my eyes have to shift back and forth and back and forth between the images and my computer screen to make sure my voice activated transcription system is understanding what I am dictating. My reports are filled with useless gibberish such as standardized statements about using dose reduction on every CT scan. We won't get reimbursed if we don't include the statement. But this is not information that is needed by the ordering physician or the patient.
The radiologist is also penalized if we don't dictate into our report some approved symptom or indication for an exam. Even though the radiologist is not the doctor ordering the exam we are held responsible for the appropriate indication. For example someone.... has decided that "extremity swelling" is no longer a reimbursable indication for a lower extremity Doppler ultrasound. So we have to search for some other reason to dictate into the EMR for documentation purposes. Even though extremity swelling is an EXCELLENT indication for this exam.
Cost of EMR and measurement of "quality" is increasing cost of medicine and no indication that it is improving outcomes.
7
The EHR is an important archiving tool(and absent interoperability and portability amongst other systems) does make information access an improvement over paper based records-outpatient clinic based or on inpatient services, and most importantly in the ED "sharp point". However, it's injustice, and, yes, it is violation of the sought after "Just Culture", is in placing clinicians as entry agents, archivists, and curators each which interrupts workflow and the social context of patient/physician intercourse. This is amplified in the teacher/learner dyad of teaching institutions. We shall look back in this era and lament as to how we permittted the valuable time resource of clinicians to be consumed by clicking and typing tasks. Also, it has been demonstrated by cognitive scientists that writing(hand) a narrative is a superior cognitive and meaning embedding task than typing.
.
4
The system will be easy to fix.
1. Start with Medicare contacting only with physicians on salary and capitate those systems.
2. Reward those systems with no fault insurance reform.
3. That frees up 30% of the medical costs that are worthless to pay for reform.
4. Use that money to pay for innovation.
5. While you are at it, reform the medical schools. Start using biostatistics as the weed out course, not organic chem.
There is no other system in the world that has a trillion dollars a year of wasted money that can be extracted to pay for healthcare re-engineering. EMR’s are a small part of the problem. The payment, malpractice and education systems must be reformed first.
Van Hargraves MD
2
While I feel great empathy for the doctors negatively impacted by Electronic Record keeping systems, I do not feel much sympathy. I'm reminded of my years teaching neurologically impaired children; I spent all day teaching, and then every evening evaluating their work, record keeping, and then planning individually designed lessons that built upon their progress. It's what I had to do for their best chance at learning.
During my teaching years, I was also seeing doctors at a University hospital for what turned out to be a rare progressive disease. In those beginning years of evaluation, my doctors never called me with test results and rarely returned my calls to answer my questions. They were extremely kind and compassionate when they saw me, but once I left the hospital I was on my own.
It's a huge relief now to have access to all of my lab reports and the documentation of my doctor's visits. It makes it easier for me to understand what's happening to me and to share information with the many specialists I must see. It gives me a sense of control that I lacked back in my early days of diagnosis and I don't feel left alone in the great unknown.
I never mind when doctors type as we discuss my symptoms because I know I'll leave with information I need. For those doctors who resent the time it takes to use electronic record keeping, please know that some of your patients appreciate and depend on those efforts.
7
What you describe in accessing results and records is truly a benefit of computers in healthcare and I don’t think the article indicated otherwise. But EMR’s are death by a thousand clicks. The overarching principles of 95% of these federally mandated systems are maximizing payments and minimizing legal exposure of the EMR’s owners. What you describe in your teaching career is not greatly different from what doctors have always done. At 61, I’ve long anticipated ways in which IT could facilitate good patient care. I promise you, we are not there.
8
I'm in my second year of family medicine residency, so I've grown up, as it were, with the EMR. But Thursday morning, our clinic network went down for almost an hour, and we were given an old-fashioned paper template. I was amazed by how liberating it was. There are lots of disadvantages -- I'm probably the only person who can read my writing, it's impossible to search for a medication or diagnosis to figure out the rationale, but it was so patient-friendly and fast (at the time -- that evening I got to type all my chicken scratches into the EMR).
6
All I can say to this article is....Amen.
7
Most existing Electronic Health/Medical Record systems are essentially billing enhancement tools masquerading as healthcare records. This, more or less, is what I was told by a leader of one of the most respected healthcare organizations in the country.
The ability to securely access and share critical patient information (diagnoses, medications, allergies, etc.) is essential to providing competent care, especially when a patient is incapacitated or receiving care someplace other than their normal doctor's office, but EMRs should be built around just that, not all of the hyper-detailed coding required for billing and quality measurement. This is why it's also insane that despite government promotion of EMR "meaningful use" standards there's no widespread interoperability requirement between different EMR systems. Much of this nonsense would cease to be an issue if we didn't operate on a fee-for-service payment system, let alone have so many insurers all negotiating different rates with each healthcare provider.
18
You are so right. The emperor has no clothes. The charade has been exposed and obvious for years but there has been no improvement in EPIC, Cerner or any of the Electronic Health Billing Records. Call me Don Quixote, dreaming the impossible dream that some day EHR will actually fulfill the promise of becoming a tool that helps improve quality, safety and efficiency of health care not a billing tool and burnout accelerant it is today.
8
I am an internist in practice for 26 years. We were early adopters of EPIC 17 years ago. EMR are so much safer for patients and help doctors provide better care. With practice you can decrease your administrative burden. Don't be afraid to delegate what you can. I really don't think the EMR distracts me from patients but it took a while to get to that point.
4
Maybe it helps that you are in private practice. My large organization uses Epic, and every week there are more buttons that must be checked or we will be dinged for quality (one marker is simply checking the button). Every time I open a note, even if it's just to finish the note I started 2 minutes ago at a different computer, the yellow "best practice" boxes reset themselves and want to know what my plan is for this or that -- often things that are already documented elsewhere in the chart!
My favorite is the flu vaccine documentation -- every encounter, even a phone call prompts me to give a flu shot. I love flu shots and like to think I'm relatively good at talking patients into them, but last I checked it was still pretty difficult to give them by phone!
10
I'm in. It is past time we started standing up for ourselves and our patients.
6
I'm in solo private practice. I use paper charts. Medicare penalizes me, but not enough to make up for the productivity and quality I have maintained this way. My paper charts never malfunction and have never been hacked. After half a life in practice, I am not burned out and am happy to go to work each day. I have no administrators living off my work, telling me what to do. It's still the good old days in my office. What good is getting higher reimbursements if the joy of practicing medicine is drained away?
13
The elephant in the room is that the reason EMRs were created in the first place is because the hollowed traditions of medical care did NOT generate superior outcomes. Fallible human minds, no matter how bright and educated, are a single point for failure. In the long past days (that never truly existed), one physician with limited education could represent the state of the art to their patients. A 3 line scrawled note card was all the documentation that was needed. As soon as the need arose to communicate the state of the patient (to/from specialized colleagues, to payers to "justify" our ever increasing charges, to anyone who sees healthcare as a process with handoffs which is more than a simple transactional doctor-patient event, capturing the facts of the event assume paramount importance. That said, what we have as a medical User Interface is the rough musical equivalent of 2 bit analog-to-digital conversion. Crude, forced, seriously corrupt and thus full of noise. Yes, there is MUCH room for evolution. But the clatter of most posts on this thread is frustrated whining for a time that was really far from perfect in different ways. As much as it galls the ego of the typical physician, we are not all that smart as one-off operators. The power of medicine is in our collective care of the patient. So try using your brains to understand how IT works, where it is headed, & how the tech titans (and the policy folks in DC) can facilitate a cleaner, shareable chart.
6
Yes, there is frustration - we are frustrated that technology is woefully behind as in the current version of EMRs .We are whining that we are given a frustratingly inefficient tool while we are asked to increase productivity. We are breathlessly waiting for the visionaries in DC and IT to move us neanderthals along into the Information age. We are whining because we care.
11
Indeed! Thanks for not using the 'new' abbreviation EHR, H for health. Nothing healthy about any EMR. I've been using them for nearly 20 years and the only decent one was created by a group of family docs! All the rest did not have patient care in mind are more geared to billing data and not intuitive, efficient use of time.
The best suggestion is that these should be subjected to approval before being on the market. This is the worst part of the 'free-market' as all vendors have their proprietary software and none of it interfaces with each other, a huge problem! This is essentially an unregulated industry.
George F. Smith, M.D.
6
My primary care physician of many years threw in the towel. She now works at an urgent care clinic, where the charting isn't insane.
5
Good rationale article by a MD. We patients are not out to lunch as they say we notice the affects of the digital world. Our issue is we find being a patient scary as we are thrust into what I call a vortex of the medical establishment. From just imitating that troublesome call for an appointment and all the anxiety is something most have no experience with . We certainly did volunteer to be become a patient. What seems probable as less and less dedicated young folks who may aspire to become a doctor will turn to some other profession. It just may not be worth it. People avoiding seeing a doctor is a common event.
2
"The Terminator" was wrong. The machines won't need a bloody war to win- death by a thousand clicks will take us out. Seriously, the interface is completely wrong-I should be able to type "Upright portable CXR-SOB" and be done with it rather than click a half-dozen boxes, scrolling through myriad diagnostic codes and have the added fun of selecting "mode of transport." Unfortunately, EMRs seem designed primarily for billing and the number of people that understand good design AND user needs is about 6 in the entire country.
9
Another issue is that there are so many different EHRs and they don't talk to each other. We have at three 5 different systems in our hospital. The inpatient record doesn't talk to the outpatient chart which doesn't communicate to the emergency room or the X-ray system. None of which are linked to billing. We are losing millions of dollars a year in our hospital system for this very reason.
I also hear many of my colleagues dictating insert knee exam, or insert shoulder X-ray. So everything is templates without any real thought.
But in truth the horse is already out of the barn as physicians we have allowed ourselves to be dictated to for so long that it is now too late to regain control of our own medical practices. So it is too late to rebel its easier to retire or just quit.
5
There are so many problems with electronic medical records, i don't know where to begin. the only good thing about EMRs is the centralized location of information. I review medical records for a living. the information is remarkably redundant and confusing and the number of pages of a medical record (paper copies) has quadrupled. Physicians and their assistants and nurses spend more time inputting into the computer than actually looking and examining the patient. I can understand why physicians are frustrated with it.
12
I agree the time spent on EMRs is absurd.
Have people in the health profession considered designing an efficent, user-friendly system that meets the needs of doctors? Creating a new, innovative position to take care of the administrative tasks while reserving diagnosing, etc., for doctors?
Couldn't a portion of the billions of revenues received by healthcare systems be invested to make the systems better?
Banking has done it. Defense has done it. Why do healthcare systems choose to use archiac sytems? With all the time spent, why do my records/encounter notes contain more errors than facts? Why isn't there a patient module to enter my truth of the visit? Why am I told by providers I have to physically drive to the practice location to pick up a pice of paper--a lab result or progress note thay I need for my records-as if it's 1975?
And this is all the fault of the government and insurance companies, right? No; healthcare systems are not helpless to change.
It would be refreshing if you reported from a mindset other than helpless victim, once in awhile. Thanks for raising this topic.
1
Excellent article! It will take doctors and nurses organizing to save the patients from harm inflicted by unfocused doctors who are only half-listening.
I don't have a lot of faith in doctors' ability to organize and push through improvements that don't increase the bottom line, just based on history (would be pleasantly surprised if the author of this article led the charge to organize).
But nurses do have that energy. Go RNs!
3
I'm unclear why you feel the need to bash doctors. Doctors and nurses have different jobs but are part of the same team.
7
The real problem here is that doctors are the lemmings. In order to survive we sold out to large, often publicly traded, corporations who answer to shareholders. These corporations have been incentivized by insurers and the government to create cumbersome and large EMR systems that don’t communicate with each other. Doctors used to think; today we input data into a database in ways few can understand. Oh, and one reason everyone sold to big corporations, yes-the EMR “mandate” because it’s too costly for small/independent docs to implement and maintain on their own. The doctors should unionize and bill every 6 minutes like our lawyer friends.
5
Our handwashing is now electronically tracked - in our EMR.
4
The ratio of time spent helping patients and time spent filling out “busy-work” documents on the electronic medical record is out of proportion. I aspire to go into the medical field one day, but it is discouraging to know that my work days could be overwhelmed with paperwork. I understand that the EMR system is important to maintain all medical records but it should not be the only system handling all health care issues. The health care systems around the country should be more focused on face-to-face consultations with patients. Being a doctor should not be a “sit at a desk and fill out documents” job. Being a doctor should be so much more than that; it is about helping people. Doctors can’t helping people if the EMR systems are absorbing all their time. Time management will be a key component in fixing this problem. We still need EMRs but we just need to manage them differently/more efficiently.
1
Here's the main problem with the EMR: like other forms of technology, it is being used to assign clerical and administrative tasks to individuals who used to not have to do those tasks.
Physicians go into medicine expecting to be high-level thinkers. That's what we enjoy, what we are paid to do, and most importantly, what our patients expect us to do.
However, with the advent of the EMR, we increasingly volunteer our time in order to replace a small army of administrative and clerical workers who used to be paid to support our work. Not only do they no longer have jobs, we have many hours of additional unpaid and ungratifying work to do.
23
I hear your pain and frustration with the volume of paperwork (now electronically foisted upon us) in documentation of the provider-patient encounter. As a registered professional nurse, critical care clinical nurse specialist, and educator for over 40 years I can tell you that my nurse colleagues and those in other disciplines have been drowning in documentation requirements for ever. This is not something new, but certainly the format, complexities, and mandates have evolved to a system that overburdens everyone on the health care team. Time to recognize that we are all in this together and that it is not only our physician colleagues that are struggling. Perhaps an interprofessional collaborative approach might generate some important streamlines.
5
Doctors need to unionize. Period.
9
Agree- but at least in primary care we are too buried under virtual and real paper sent by insurance companies.
Another problem with the records is that when I described symptom X my doctor checked the box for problem Y. I protested that I knew what Y was and that was not what I had, the problem was X, but she said there is no box for X but Y was the closest to it.
Then, every time I saw a doctor who is hooked into the same medical system, they use up time by kindly asking me about my Y. I asked for Y to be removed from the record and just don't talk about symptom X with this group of doctors.....
8
The parasites that add no value to the system are draining money expotentially. The two biggest ones are HIPAA and EMRs.
19
We are not going to be able to get rid of the EMR giants that are out there, so the question is more how do we manage them? Here's the thing: a great note takes TIME. Precious time. Extra time outside of the exam room, and away from your families & friends. We've created an insert template into these systems to get through an incredible note in much less time. Don't give up on quality care but don't give in to pointless clicking! cdnotes.org
The EMR "revolution" has gone off the rails. My observation, after studying user and technical manuals for a number of common EHRs, is that the designers & sellers of these systems seem to have tried to create templates (cheat sheets, as we used to call them in third year medical school when we were learning to do H&Ps) for every granular observation, finding, and possibility in medical encounters.
I have been stunned by the enormity of the attempts to create template choices for everything.
As just one example, here is some online training material for an ED EHR: https://www.inova.org/External/etraining/PICIS_ResidentTraining.htm
Is the atomic taxonomization of an ED encounter to this level of granularity, for example in section 8, Physician Documentation really necessary?
I've been writing on these issues for decades now. See my Drexel Univ. website "Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties" at http://cci.drexel.edu/faculty/ssilverstein/cases/. It's not been updated in a few years, but highly relevant.
4
EMR's are never sold based on their increase in physician efficiency. They are sold to administrators based on their supposed increase in administrative efficiency--"look at all the cool data that is now at your finger-tips"--data that is now physically inputed by physicians. The numbers are compelling. If an EMR takes only three extra minutes per patient and if a physician sees twenty patients per day there is a loss of one hour of patient care time per day--five hours per week--twenty hours per month. Most importantly it has caused a deterioration of the doctor patient relationship. Many of the subtleties of nonverbal communication are lost if we don't look at our patients when they talk to us but instead focus on our keyboard.
Many have advocated for scribes which does increase efficiency but at a cost not only in real dollars but a cost to the patient in introducing another person into the room and into their private lives. When there is a scribe in the room the patient will often look back and forth between the scribe and the physician--not knowing for sure who they should be talking to. How much important private information goes unsaid by the patient because of an extra person in the room?
The only solution to an effective EMR is a system that is lightning fast and can respond to voice command with complete accuracy. I suspect someday we will get there--but for right now I still can't get SIRI to recognize my wife's name and call her on my phone.
11
Recall that it was time to take action back when the 2000 IOM report 'To Err is Human: Building a Safer Health System' came out, when it estimated that 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors that could have been prevented. One major result was an increasing emphasis on using information technology for error reduction and quality improvement. EHRs (Electronic Health Records) resulted. BTW, EHR is a more accurate and accepted term (look at most health informatics text books) as it encompasses the 8 core functional areas identified by the 2003 IOM report (health info and data, patient support, results management, electronic communication and connectivity, decision- support management, reporting and population health, order entry management, administrative processes). Change is difficult but necessary. We went live with EHR back in 1995. 3 months later I came home one day from my family medicine clinic 2 hours early. My wife surprised, asked me if I quit. No, I got done with my charts. Practice helps. So does asking for assistance from someone in your system.
3
A year and a half after installing EPIC I have reached some level of competency with our new electronic record. However, the comments made by the author about percentage of time spent on the electronic medical record (EMR) are right on target. If I am to have a meaningful interaction with a patient, it necessitates that I defer completion of the record until after the clinic is over. Thus every day I see patients ends with an additional 2-4 hours of work. As I am at the end of my career, I am unwilling to do several things that would improve my efficiency: 1. Complete my medical records while I am with a patient. I shudder at the thought of elevating medical record completion over a meaningful patient interaction. 2. Use templates for everything. Templates meet billing criteria, but are so general (and filled with un-necesary information) that they do not serve any useful purpose (other than for billing purposes). 3. Generate reams of repetitive data for other physicians and care providers to wade through to understand the patient's problem. It is this last issue that needs more focus. The march toward improving care has always been about simplifying and focusing an often complex medical issue. The current electronic medical record (EMR) in no way contributes to improving care. It fragments beyond belief. Trying to read through the notes to understand the "thread" of what is happening with a patient has become impossible - a joke. Time for phsicians of the world to unite?
28
Dr Ofri's comments are exactly on the mark. I am an internist in practice for over 30 years, and in discussions with other physicians we all feel as Dr Office describes. EMR is destroying the practice of medicine and needs to be corrected.
23
I've had so many tests and seen so many doctors for my rare disease in the last few years that I've lost track. The thing that EMR have made easier for the patient is the print out I get at the end of my visit to put in my folder and show to every doctor going forward. I can show them my most recent blood tests instead of trying to find my doctor's contact info and signing a release form for them to fax or send it to the next destination. I have more control over all my tests and doctor's notes.
3
That helps a bit, but most of the information is hidden from the patient. In my experience, doctors want the full record, which includes the encounter note.
Ironically, key information im the EMR is hidden from the patient, the primary stakeholder in the transaction.
4
Electronic Medical Records are but one of the reasons doctors are leaving medicine. The insurance, pharmaceutical, med mal, hospital and EHR industries are all inserting themselves between patients and their physicians and extracting time and resources from physicians and patients diminishing the ability of doctors to deliver better outcomes at reasonable costs.
https://www.linkedin.com/pulse/american-physicians-putzes-howard-green-md/
10
Is anyone looking at how this is handled in other countries that have better outcomes at lower cost ? The UK NHS has electronic medical records - I'm sure with its own set of problems, but citizens of the UK live longer than US citizens and pay less than half as much in medical costs for the privilege.
4
If management insists on EMR, then every practitioner should be accompanied by a scribe (trained and bound by confidentiality) who will transcribe into the EMR while the physician actually interacts with the patient.
21
Best idea I've heard in a long time.
Who pays for the scribe, the EHR company with the lousy UX or the physician?
3
Like so many other things EMR is a good idea gone bad because it was too profitable. What is needed is an absolute, zero tolerance cap on the administrative costs in health care. I think 10% of the total would be fine. Then you wouldn't get anything that wasn't necessary. If you still think you want extra bells and whistles at every step, just look at your health insurance premiums.
14
Documentation burdens due to insurance, regulations, compliance, quality and other areas have been introduced simultaneously with EMR implementation. Providers are paying for the sins of their predecessors who were paid for services or products they did not supply, or the patient did not need, and they falsified their documentation. I wonder how long it would take to write a progress note on paper now with all of the current documentation requirements....longer than the five minutes noted in one of the other responses.
EMR interfaces are confusing and over stimulating - poor layout of way too many items. The EMR vendors have a lot of work to do in this area. On the other hand, you can find all of the records on a patient seen in your health system and other systems almost instantaneously. Orders are clear and concise and legible and instantaneously sent off without delay. I recall having piles of paper charts on my desk on complex patients, and sometimes that was only the most recent information. The older items were in a warehouse somewhere.
My colleagues write notes that range from concise and high quality to large bloated poor quality notes. They did this on paper too. I believe you can make the most of the tools you have.
1
Concise and quality should be the value. Why settle for less? As the article points out, patient care should be at the forefront but how do practitioners not get burnt out when they are spending nights and weekends completing a "quality" note? The levels of demand are staggering. I'm working on a way around that. Check out our inserted templates on cdnotes.org.
1
All my physicians have access to a common EMR. This includes 10 years of paper records transcribed before the hospital and clinics went "electronic". I can now see 20 years of blood test results, prescriptions, and diagnosis as a patient (on my home computer). As can my Doctors, current and future.
This is "another" form of medicine, but better, in my opinion, as a former biostatistician in university medical research. Longitudinal medical histories are critical in the diagnosis and treatment of chronic diseases, and that's what most of us have. EMRs let you do epidemiology across patient populations; spotting outbreaks of infections and cancer clusters.
I just don't see a downside to this. Some Doctors do seem to struggle with typing and finding screens in the apps, but the majority [my doctors tend to be young] touch type and have used computers most of their lives.
I no longer have to undergo redundant blood tests, X-rays, scans, etc because specialists can't share lab results. I have had visits to a Doctor where they want a test. I go to the lab and then back to the Physician, all in the same visit, because they now have instant access to lab results.
2
Nobody is arguing that EMRs are not data storage vehicles but they are just that - they don't add efficiency to the workflow of frontline providers . On the contrary they add layers of extra work and are not smart .
I will give you an example-
If I have to find out how much weight a patient has gained over months, I simply can't simply find this out - I have to click click click click scroll through reams of irrelevant screens to get to it. In this age of self driving cars and talk of colonizing Mars one would think that there would be more to expect from EMRs which deal with people's health and well being but no.
EMRs in their current version add layers of extra work - they are simply not intelligent enough and lagging behind. Part of it is failure to integrate systems due to privacy, bureaucracy etc but really you should try it while you are trying to really give care to your patients before you can understand -I mean this sincerely!
18
Perhaps you can ask the patient how much weight they gained?
1
If it were that simple! Not every patient I see is as well informed at the commenters in this section.
1
Here Here Dr. Ofri. Thank you for a succinct critique of the EMR, the latest obstacle in our battle against disease. I would add this: the growth of meaningless information that the EMR promulgates further multiplies the problem; it creates what I like to call anti-information. Best one I heard of to date was a 3 page regurgitated review of systems and a single ending line saying the patient no-showed for the appointment.
I don't wish to quibble with your fine essay, but fear your prescription. Any top driven effort to streamline our burden will undoubtedly require more keystrokes by We the Users. To paraphrase the "Fatman" from the House of God: "Show me an EMR that only triples my work and I will kiss your feet"
WJSmith, MD
16
Other industries have burdensome administrative requirements yet they create tools and systems that work for them. With all the talent and money in healthcare, surely it could do the same.
I think the reason burdensome administrative requirements exist in the first place is that the industry did very little to improve things. Nothing us really set up for the patient.
2
Documenting a visit by pen used to take 5 minutes and now takes 15. I spend 2-3 hours every night finishing "feeding" the cursed EMR . Another gripe (that patients don't comprehend) is a complete lack of interoperability. It remains true that it is often easier to repeat a test than get results from another office 10 minutes away. EMRs should be MANDATED to be interoperable and communicate with each other. My large single specialty group just changed EMRs (the old one was terrible) and the change is agonizing. Everyone knows this and so it serves to keep groups locked into terrible EMRs as well.
20
I can see how it would be easier to reorder the tests. But wouldn't it also make sense to allow patients to get his labs as soon as resulted?
I have tried to get my lab results to share with other doctors numerous times, only to be told I am not allowed to have them; that they can only be released to the ordering provider. Yes, I repeat--I am not allowed to get my own test results!
Quest will let me obtain them through a portal but not until 5 days after the ordering physician gets them. If I don't have a computer, I have to wait 30 days to get a copy.
Healthcare providers are making it more difficult and costly by hiding information from the patient rather than allowimg direct access.
3
Some blinkered bureaucrats have decided that the best use of their most valuable and expensive resource is to burden it with clerical work. Other specialized-knowledge workers (Lawyers, Engineers..) have long since dealt with this by simply calling the imposed burden what it is: work. And billed hourly for it at professional rates. I suggest Physicians do the same.
28
Amen
1
Bill whom?
Great point. Lawyers also do things like hire paralegals and assistants to do work that doesn't warrant the high $/hour that the actual lawyers command. Some providers are starting to use medical scribes, but that essentially means that these burdensome EMR systems have now necessitated an entirely new role in healthcare to manage them (to say nothing of the IT maintenance needs and the cost of the system and all of its upgrades). Providers already tend to have tight budgets so scribes are a hard cost to absorb. Providers should indeed seek to demand some sort of reimbursement for recordkeeping hours, regardless of who does them, and especially from government payers (Medicare, Medicaid, VA) when meeting EMR "meaningful use" requirements is one of the contingencies of doing business with them. It's unfortunate, though, that this would be yet another cost added to an already exorbitantly expensive system, although perhaps that might spur some EMR redesign to markedly improve efficiency.
2
The NYT should devote more attention to exposing EMRs -another example of technology touted as the panacea for all ills but that falls way short and brings its own set of problems.
Nowhere else in medicine has something so not evidence-based and so unregulated as the current iteration of EMRs been foisted on doctors and patients alike. Reams of useless data to sort through with very little intelligent help from the software. My smart phone which is for play is way more intelligent than the EMR I use to deal with life and death ironically -need I say more! Patient care is not a winner in the EMR game.
The cost of the excessive documentation burden on the frontline staff is a travesty!
20
In 2016 I wrote an essay "More on uncoupling clinicians from EHR clerical oppression."
I observed that:
Correction calls for modifying/softening cybernetic-enthusiast ideas like "paperless" and a more appropriate allocation of computer-related tasks. Refocusing on "Clerical work for clerical employees; clinical work for clinicians" would be a good start.
That essay is at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from...
2
I have read most of Danielle Ofri's books, and appreciate her wise perspective. It has helped me to be a better patient. Solving the difficult EMR problem is one that will take considerable effort. I think it will be eventually solved.
In the meantime, I know that my physician's time is short and I go to the visit well-prepared to use the valuable time as efficiently and productively as possible. Be brief, be blunt, be gone.
3
I have written this before. The force to make EMR's confirm to one basic format is in the power of those who take it.
When Medicare refused to reimburse any claim that did not come in on a HCFA 1500 form by golly EVERYONE filled out those forms or not see a drop of money. Insurance companies jumped in the band wagon and thought if it is good enough for Medicare it is good enough for us. That is why the majority of insurance forms all look the same.
Doctors refuse to unionize because it does not appear professional. Well here is a good reason to unionize and make it your first cause.
15
the EMR is only as good as the information entered but as a patient I love it. I can find when i had my last CT scan, track my Haic, read and even correct the pathology reports on my cancer. As anyone who has ever gone through mountains of paper records knows this is a big improvement. So think of the data entry as a memory bank for patients and doctors to improve care. In the long run it may save almost as many lives as hand washing.
1
The E.M.R. also creates stresses for many patients who are concerned about how this technology has affected the physician/patient relationship. We miss the eye contact, and we are never certain when to speak and when to be silent as the physician reads and keys in information. We worry about erroneous information unintentionally being entered into the record that we won't know about because we don't have complete access to our own charts, even with the use of online "patient portals." We worry about providing highly private information regarding our medical history or health concerns that can be viewed by any administrative staff person or insurer. We worry about keeping our visits brief and limiting our questions because of time constraints.
And, equally important, many of us sense that our physicians are stressed and frustrated, and we therefore worry about them as well.
31
First things first -- the writer did not note that EMRs were locked in by the PPACA. Res ipsa. It is an aggravating situation.
Second, many of my MDs use "medical scribes," who are typically pre-med undergrads. Who, for minimum wage, record what the MD says and does, onto laptops.
Third, for myself, I always write up a summary of my condition and e-mail it to my PCP/MD, on her secure server. I am my best physician, I care about me. My MDs are nice people, and I am trying to help them, because they are the ones who went to medical school, not me.
1
Thank you for this article. It was a nice break from all of the charting on patients I’ve been doing this evening at home. Probably only a few more hours of typing to go. Pretty standard night here.
22
I have long argued that the best approach to being more productive is to not allow doctors to write anything! Rather they should have an assistant who writes all down during the patient interaction and then have the MD (or DVM in my case) review and approve the results.
The documentation assistant will more than pay for themselves with increased productivity from the doctors and will reduce some errors
11
I was just about to comment this same thing. I am sure that later the doctor will have to go in and add some perspective and clinical support, but the basic facts and observations of the visit could be handled much more efficiently by a skilled medical typist. We don't ask judges to do trial transcripts, right?
3
Thank you for sounding this alarm. Progress is sometimes measured in small steps instead of giant leaps, so if a critical mass of doctors can tip the scales in favor of even a small change to this system, it will be heading in the right direction...for them, and for their patients. I don’t know what the answer is, and I suspect you don’t either, but something will have to give.
2
Amen to that sister doctor! Nowadays, inpatient rounds is largely sitting in a room around computers! I don't see any measurement being made of the amount of time that is truly spent attending to the patient alone. (My EMR gives you a better weekly "grade" for placing your orders while in the exam room, as if working on the computer in the exam room is a benefit to the patient!).
The truly sad part of this is that trainees will believe that this is a reasonable way to provide medical care!
9
Bravo Dr. Ofri!
May the universe grant you a larger megaphone. Voice recognition software will help but is very slow going.
4
From the patient's perspective . . .
My last internist was an excellent physician and on the faculty of the local medical school, extremely thorough and knowledgeable. She recently retired from clinical practice and restricts herself to teaching duties. I expressed my regret at losing her and she mentioned her reason: she was spending her evenings mostly keeping up with the EMR as well as some keeping up with the literature, and wanted to spend some time with family.
7
Very sad indeed. For myself, a medical informatics specialist since the early 1990s, I can state clearly this was not the future we (or the pioneers who taught us) envisioned.
5
That's happening more and more and it's the good physicians that we are losing.
Physicians looking down at their computer has become one of the most common patient complaints.
Patients are acutely aware and annoyed by the excessive screen time, but the health care providers truly have no choice.
This is an even greater issue in institutions that employ physicians and measure their quality purely by the boxes checked off. Unfortunately the decision makers are no longer physicians who deal with patients daily, and currently; but rather business, risk management, and insurance people.
9
This is a really interesting piece. I use a "patient portal" to contact a few of my doctors and have often wondered how having to answer my (and all of their patients') electronic messages impacts their practice(s). I realize this isn't the EMR but it's another addition to their work that must, ultimately, detract from the time (and energy) that they give to meeting with patients in person. I'm not sure what I, as a patient, can do but it's always good to have added insight.
5
I'm a family physician who loves my patient portal. I think it's an example of technology going in the right direction; which is to say increasing accessibility (to records and advice), empowerment, and convenience for patients. It's actually simplified a previously annoying task (writing and mailing a letter about test results) - now I can just push them to the patient portal with a quick note about what the results mean. In addition, I WANT my patients to ask me questions, and I don't mind answering non-urgent questions at my leisure (think: on my couch in the evening. That, unlike clicking boxes about quality measures, feels like the work I'm supposed to be doing) Often there are portal message streams that are more effective and efficient in managing a problem than an office visit or a phone call would be; and if a patient asks questions that need more time and attention than is practical via electronic message; I just call them or have my assistant schedule an appointment. Now, if the REST of the EHR could be more like that, it would be better.
6
There’s always, regrettably, the legal reality that doctors fear accusations of medical malpractice, and electronic records perversely may be a defense against that, or the source of it.
4
Med mal suits due to EHR problems are up 12% recent study demonstrates
4
Why not have an additional person in the room who is tasked with filling out the EMR during the visit? The doctor can review the EMR at the end of the visit to make sure it is correct. This would unburden the doctor and the additional person would cost less than the doctor.
5
Who is going to pay for that ?
Physicians are treated like factory workers and must produce a certain amount of widgets to pay for the suits and bean counters telling them to "be more efficient " and see more patients. Quarterly profits not, quality of care is
what matters to the suits and bean counters.
4
Amen. I am an employee occupational medicine and urgent care doctor and with EMR it takes twice as long as compared to the old paper charts. Our patients are pretty simple but often have multiple body parts involved and each elbow, knee, neck, back etc complaint requires what amounts to a useless 3rd year med student history and exam documentation. No one uses the info clinically nor do they even has access to it should a different doctor want to follow the case. She wouldn't be able to find pertinent actionable info as its drowned in a sea of useless "negatives" (as no the patient does not have a list of symptoms and signs from A to Z). It can take 200 clicks and and 20 or different windows/pop-ups just to document as required by our EMR and management on one patient. It also is "dirta" - bad data as one has to make it through as fast as keystrokes will allow. I understand I have to do this largely to so the massive medical corporation I work for can get paid at a higher rateper patient visit - so called upcoding - as thats where the profit is, not in listening to a patient. Why can't we abandon this nonsense of 5 levels of patient complexity as it has turned into a big waste of MD time and borderline fraud.
9
Actually a lot could be improved medically speaking. E.g. why don't I have my blood tests that determine the amounts of my meds for high cholesterol and diabetes 2 pre meeting with my MD? Also blood pressure needs to be taken in advance. I should be asked routine questions by a machine... which does not mind repetition unlike a person who does and also which does not forget things.
Why isn't my BMI automatically figured out by the MD's computer.. I have to figure it out myself.
Why is there no counseling-- on weight and diet_- all of which could be done with an interactive computer program?(I have had ONLY two MDs one my retinologist ever tell me I was overweight.. (i was and I lost weight both times)
Why is there so little counseling on diet--what to eat -- how much sugar how much fat? When obese/morbidly so people tellme their diabetes is under control with meds and they see their MD, who does not tell them to lose weight, every three months __ I don't know whether to laugh or cry.. Or the ex- MD who tells me his cholesterol levels are normal while I stare at the statin on the table (delusional?? or unable to express himself -- controlled is the proper word certainly not normal. PS my gerontologist mostly seems to send me for blood tests and to specialists -- the last mammogram and colonoscopy EVER finally ... but my problems imperfectly controlled with meds may have more to do with diet.. and exercise. Never discussed.
2
Make America Sane-
"Why is there no counseling-- on weight and diet"
Because then the patient will run home and write a negative Yelp review on the doctor complaining that he called me fat
8
Epic allows patients to submit data , history and review of systems.
I just about fall to my knees and kiss the ground when someone uses MyChart access optimally.
More often then not patients are signed up for it, can’t access it because they lost/forgot password.
Then I get a patient complaint on press ganey that they didn’t receive lab results.
I agree that health care providers spend too much time on documentation. EMRs should and can be designed to lighten the burden for providers. The barrier here is that there is no incentive to improve EMRs for the end user- the provider. EMRs have been developed by administrators and by businesses, with a model that rewards them more with complexity. Another major problem is the documentation related to insurance authorization, pre-authorization and Medicare. I am a physical therapist and must provide documentation just to get authorization for one visit in some cases. This is not only a problem for providers but delays patients seeking conservative, and often safer and less expensive, treatment.
Thank you for sharing your story and for your commitment to your patients. I believe the technology for a better EMR is already here, however we need more squeaky wheels like ours to make it happen. We end users- the providers and the patients with whom we work- need to speak up more, like you, Dr Ofri.
7
A more efficient use of the physician's time, and one that is actually less costly, might be to go back to employing another person to handle all of the administrative work.
The doctor can look up the patient's history on the EMT at the beginning of the session with the patient, then concentrate on the patient.
A trained medical assistant or medical secretary can enter the necessary information into the EMT while the physician is examining & talking to the patient. The MA could pull up data needed.
Before computers, physicians' practices used to employ medical assistants and medical secretaries. They did all the administrative work: calling up patients' charts, scheduling appointments, taking the patients' vitals before the doctor saw the patient, entering the information into the chart.
All of those professions were virtually eliminated or seriously reduced when computers were introduced; it was thought that the physician could easily enter the information into the program, thus saving money.
However, as many "streamlining" and cost-cutting efforts have shown, eliminating lower-paid staff means that the higher-paid staff spends a considerable amount of professional time doing non-professional work. Thus, such efforts are not cost-efficient.
I think it's time to bring back trained medical assistants and secretaries, to do on EMT and computer programs what they used to do by hand.
The physician would be freed to concentrate on the patient, and money would be saved.
12
You fail to mention the cost of the EMR. Bringing back an MA or secretary will require paying that person as well as the cost of the EMR.
4
As a full-time hospital-based physician I agree one hundred percent; thanks for writing this. My hospital uses a relatively new version of EPIC, and the work-flow is horrible. I can send 10 text messages on my iphone and read 10 emails on google without interruption, but heaven forbid I open a patient's chart in EPIC to do something simple like make it clear to the nurse that "THE PATIENT MAY TAKE A SHOWER" - I will first have to beat back five irrelevant BEST PRACTICE ADVISORIES about signing orders written by some other doctor.
14
Ditto on the best practice advisories! My favorite is being asked to give a flu shot on every phone encounter - last I checked there's still no way to give a shot over the phone!
2
I totally agree with Dr. Ofri. A few additional thoughts:
Her article is a great example of the disconnect between health care administrators and the providers who actually see the patients. Many of these unnecessary EMR requirements were implemented due to meaningful use. Do we need to continue all of them? Another reason for the ridiculous EMR requirements is due to insurance billing. How can administrators work with physicians and other providers to comply with national requirements while at the same time not ignoring the enormous burden that providers face?
Another thing that providers spend a lot of time on is arguing with insurance companies. I've seen many an oncologist plead with an insurance company for a patient's life for a reasonable treatment plan. This shouldn't happen.
Honestly I think it mostly comes down to an out-of-control insurance industry and out of touch hospital administrators. Most administrators have no idea what it's like to even be in the clinic.
7
bravo to Dr. Ofri. During there all too many doctor visits over the past year, triple bypass, stoke, plural effusion, shingles, I often find myself sitting across from one of the many doctors hunched over a computer screen and key board who may ask the same question more than once. Listening or typing? To review your EMR records it's all to enlightening to see the errors included by an overworked doctor who is not practicing medicine but rather his or her typing.
5
Charting with the computer while the patient is in front of you is like texting while driving. It is dangerous and a set up for a potentially serious mistakes. It is time for providers to take back control of their exam rooms and boot out burdensome and distracting documentation!
26
And if the doctor cannot chart then, when do you think they do it? Every night for a couple of hours after the office closes? Every weekend so that there is no time to recharge and put the question of burn out not it but when?
4
you are right, you should spend most of your time attending to patients. I go to Bassett medical complex in upstate NY. I'm 85, need a lot of care and get very good care, I assume the doctors have the same EMR burden but apparently the nurses do the data entry because my doctors spend the vast majority of their time their time taking care of me. I am very grateful.
3
So true! EMR empowers the large systems and hospitals and detracts from the physician-patient relationship.
7
Agree 1000%. The problem is that the current EMR companies have monopolies on the large hospital systems that have bought into them for billions of dollars so there is no room in the market place to innovate a better system. Hospitals will pay for upgrades to make billing faster but nothing else. Why is it that I can find ANY stupid factoid in an instant using google and yet getting to my patient's last assessment of cardiac function takes click after click after click?
10
No incentives? It sounds like there are plenty of incentives to create new EMRs. Perhaps physician groups could join forces and create their own.
Ensure the system has multiple mechanisms to benefit and safeguard the patient so bureaucrats don't create regulations to do what you didn't want to do.
1
you are so right on- thanks for you article and the time you took to write it!
1
Hear, hear! The amount of time spent on non-medical work was double what I suspected. It means both less patient time, it means less time for research or collegial discussions, frantic doctors whose personal lives are being subsumed to paperwork.
A system for recording patient hx succinctly, easily accessed in the future or by different treating doctors; providing
information that can lead to better care - terrific. Fewer mistakes, easily linked payments. Perfect. A record system design mostly by auditors to meet the demands of competing data systems - insurance, government, legal, hospital administrations - a recipe for failure.
There are recoding systems in place in the world of welfare which also demand more attention to records than to meeting with people. They are in manyways self defeating - but no one outside of those fields realy care. Most people would care if their doctor is distracted or overwhelmed or simply unavailable, if they understood it was because of electronic "paperwork."
It can be streamlined but this required massive cooperation and willingness to admit that EMRs stink if they do not serve their original purpose - as MEDICAL records. ( A whole other approach to a solution relates to reducing the number of payers, and changing the pay by number approach to reimbursement in existence in the US).
6