On the Pitfalls of Going Electronic: Should Physicians Reject Bad Hospital EMRs?
Yes,
I believe they should, and with a spine, especially when they're lousy
and their design and implementation have been led by people with
superficial "certification" and/or no clinical credentials whatsoever.
And sometimes no discernible IT credentials, either, unless you
consider the "
school of hard knocks" a credential.
(More on the credentials issue below. Also see my website "
Common Examples of Healthcare IT Difficulties" for more on these issues.)
A viewpoint article was just published in the NEJM by Harvard physicians
Pamela Hartzband, M.D. and
Jerome Groopman, M.D. entitled "
Off the Record — Avoiding the Pitfalls of Going Electronic" (NEJM 358:1656-1658, April 17, 2008).
The authors note:
...
The ultimate goal of the electronic medical record — a technological
solution being championed by the Bush administration, the presidential
candidates, and New York Mayor Michael Bloomberg, as well as Google,
Microsoft, and many insurance companies — is to make all patient
information immediately accessible and easily transferable and to allow
its essential elements to be held by both physician and patient. The
history, physical exam findings, medications, laboratory
results,
and all physicians' opinions will be collected in one place and
available at a single keystroke. And there is no doubt that these
records offer many benefits. We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides.
As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems
with the way in which notes and letters are crafted. Many times,
physicians have clearly cut and pasted large blocks of text, or even
complete notes, from other physicians; we have seen portions of our own
notes inserted verbatim into another doctor's note. This is, in
essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.
Residents,
rushing to complete numerous tasks for large numbers of patients, have
sometimes pasted in the medical history and the history of the present
illness from someone else's note even before the patient arrives at the
clinic. Efficient? Yes. Useful? No. This capacity to
manipulate the electronic record makes it far too easy for trainees to
avoid taking their own histories and coming to their own conclusions
about what might be wrong. Senior physicians also cut and
paste from their own notes, filling each note with the identical
medical history, family history, social history, and review of systems.
Though it may be appropriate to repeat certain information, often the
primary motivation for such blanket copying is to pass scrutiny for
billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.
Writing
in a personal and independent way forces us to think and formulate our
ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care.
Such charts may satisfy the demands of third-party payers, but they are
the product of a word processor, not of physicians' thoughtful review
and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.
In
effect, the doctors have keenly observed that not only do EMR's impair
documentation and thinking by seasoned professionals, especially those
pressed for time, but the use of these technologies impairs the
training of the next generation of physicians. I benefited much through
learning how to properly document medical observations, findings,
differential diagnoses, treatment plans, and other high level cognitive
processes. IT designed by non clinicians with the maintenance of payor
profit as a principal motivator may be, in effect, causing a further
dilution in the quality of medical training.
Social informatics predicts such unexpected adverse outcomes of any new information and communications technology (ICT).
However, the current environment of
irrational exuberance
over Health IT, as well as the potential for capital transfer from the
healthcare to the IT and payer sectors and the motivators and conflicts
this generates among hospital management, consultants, regulators and
others, has had a marked blinding effect.
The NEJM authors also note:
Similarly,
electronic medical records can reproduce all of a patient's laboratory
results, often dropping them in automatically. There is no selectivity,
because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems. Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.
A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless.
He bemoaned the vain search through meaningless repetition in multiple
notes for the single line that represented a new development. "It's
like `Where's Waldo?'" he said bitterly. Ironically, he has started to
handwrite a list of new developments on index cards so that he can
refer to them at the bedside.
...The worst kind of electronic
medical record requires filling in boxes with little room for free
text. Although completing such templates may help physicians survive a
report-card review, it directs them to ask restrictive questions rather
than engaging in a narrative-based, open-ended dialogue. Such
dialogue can be key to making the correct diagnosis and to
understanding which treatment best fits a patient's beliefs and needs.
... These problems, we believe, will only worsen,
for even as we are pressed to see more patients per hour and to work
with greater "efficiency," we must respond to demands for detailed
documentation to justify our billing and protect ourselves from
lawsuits. Though the electronic medical record serves these
exigencies, it simultaneously risks compromising care by fostering a
generic approach to diagnosis and treatment.
I agree with these assessments, especially for hospital based enterprise EMR's forced on doctors by management.
Physician
leadership of HIT projects would be of great benefit. However, here's
what typical healthcare organizational leaders have to say about
physician leadership of HIT initiatives, in this case Denis Baker, the
CIO of Sarasota Memorial Hospital, a major medical center on the Gulf
Coast of Florida in an interview
here:
I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do.
Worse,
as far as I can tell, the CIO making that statement appears to lack
formal education in medicine, information systems, information
technology and biomedical information science i.e., informatics. (I was
unable to find any such credentials but will correct this if mistaken.)
Stereotypes of physicians do not come any more patronizing than that.
Oh, wait ... yes they do.
His statement is little different than a decade ago when I wrote
this essay about stereotypes
and observed others in influential positions holding marginalizing
views of physicians - and indeed of professional education of any kind:
Several
healthcare MIS Recruitment firms have published interesting views on
healthcare MIS leadership, views that most clinicians will not identify
with. " I don't think a degree gets you anything ," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers.
Healthcare MIS recruiter Betsy Hersher of Hersher Associates , Northbrook, Illinois, agreed, stating " There's nothing like the school of Hard Knocks ." (Who's Growing CIO's, Healthcare Informatics, Nov. 1998, p. 88).
In
seeking out CIO talent, recruiter Lion Goodman " doesn't think clinical
experience yields [hospital] IT people who have broad enough
perspective . Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues ," according to Goodman.
It appears there's been little change in ten years.
Oh, wait ... yes there has been "change." "Specialists"
and "managers" in HIT projects now undergo certification by
vendor-centric groups such as the Health Information Management Systems
Society
HIMSS.
Here's a description of the value of certication as a HIMSS
Certified Professional in Healthcare Information and Management Systems (CPHIMS):
CPHIMS
status provides both internal and external rewards. As a Certified
Professional in Healthcare Information and Management Systems, you:
- Distinguish yourself from your peers as certified in healthcare information and management systems;
- Expand your career opportunities;
- Signal
that you have mastered proven, broad-based concepts through successful
completion of the Certified Professional in Healthcare Information and
Management Systems Examination;
- Provide yourself with skills and tools to help you make a difference in your career, your organization, and your community;
- Enjoy the pride of recognition of knowing that you are among the elite in a critical field of healthcare; and
- Have a premier credential based on a sound assessment to distinguish yourself in an increasingly competitive marketplace.
Wow! "You are among the elite" after taking this exam!
Here are the eligibility standards:
Baccalaureate
degree plus five (5) years of associated information and management
systems experience*, three (3) of those years in healthcare.
Graduate
degree plus three (3) years of associated information and management
systems experience*, two (2) of those years in healthcare.
*Associated
information and management systems experience includes experience in
the following functional areas: administration/management, clinical
information systems, e-health, information systems, or management
engineering.
And now, the certification instrument:
The
CPHIMS credential is awarded to individuals who demonstrate eligibility
for the Certification Program and who successfully complete a
qualifying examination. The examination consists of 115
multiple-choice test items, presented during a 2-hour session. Scoring
is based on 100 items pre-selected for desirable psychometric
characteristics. The additional 15 test items are included as pretest items. Performance on pretest items does not affect a candidate’s score.
That is the certification that will be used to hire more "experts" in HIT.
This is pathetic. My exams to become a licensed
ham radio operator
were more challenging. I consider such a credential unmeritorious at
best, fraudulent at worst. (I haven't even inquired as to costs.)
However,
medical credentialing exams are just a bit more thorough.
By several orders of magnitude, that is.In conclusion, medicine is in very sad shape when in an era of out of control technology costs (
$100 million for an EMR?),
unclear benefit and
irrational exuberance over HIT it's demanded of physicians that they use tools designed by business IT personnel, processes and methodologies
best known for failure, produced by an industry
rife with conflicts, whose leaders often
lack substantive credentials, patronize those who do, produce ill-conceived and/or
shoddy products
whose use is mandated by non-clinician hospital managers and that as
the NEJM writers note, impair medical practice and education.
-- SS