On the Pitfalls of Going Electronic: Should Physicians Reject Bad Hospital EMRs?

 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

The title is not general enough .. it applies to all bad EMRs.

We are taught to practice EBM, but the entire medical system in the USA is being driven by insurers in a huge economic experiment that is without an evidence base.  It is leading to the development of EMRs that are meant to appease the dictates of the insurers and for legal defence hence the proliferation of template based systems.  As you say, this leads to a robotic type of medicine.  EMRs are to medicine as Power point is to presentations.

 

 > The title is not general enough .. it applies to all bad EMRs.

 Agree.  My meaning is that in the U.S., physicians in private practice are generally free to select their own EMR.  They can "reject" by not purchasing some product, especially if they have unbiased information about it and competing products. 

Those working at or for hospitals often have a system chosen for them by the organization's administration and CIO (who's usually non-medical, not very competent in the special aspects of HIT and all too often not very competent in business IT either).  There are often vendor conflicts of interest with CIO and other "C" officers as well.  There may also be a small committee with "figurehead" docs and perhaps a "Director of Informatics", a.k.a. "Director of Nothing" (no real authority or control of resources), but often the ultimate decision is up to the business and IT executives. 

 In that case, rejection becomes a political and power issue.

 A good essay on the vendor industry is at "10 Secrets the EMR Vendors Don't Want You to Know."

 -- SS

I agree with many of the points in this thread.

With billions spent on marketing and development, this technology has many flaws that need to be addressed.

They will be addressed.

I think EMR will be where it needs to be in the next 5 years or so.   When the current industry learns to change there software more Physician Speed centric instead of feature function specific.

 

 I actually don't think the EMR vendors share much of the blame. They have built businesses around trying to help docs accomplish what they need to accomplish and the EMR co's would be quickly out of business were this not their focus. The issue to me is that the doc community is being asked to do so many different things that I don't see how an EMR can be in a position to help with all of the tasks. 

For example, I have to collect a subjective hx., collect and review lab data, pay attention to P4P, answer emails, research conditions at the point of care, check drug interactions, etc. The EMR co's are basically presented with this laundry list and to service the market they have to figure out (or overstate their capabilities) how to have their product do all of these things.

A case in point is my EMR. They realized much to their credit that P4P was coming to the market and they wanted their docs to be able to succeed in P4P programs. So, they created a method to track P4P replete with reminder windows and registry reports. They have accomplished this goal but they have also created a tedious approach that takes a lot of time to accomplish and becomes a distraction for the user. 

Frankly, many of the things docs need to accomplish simply don't lend themselves to the current state of EMR technology. The end result is that we are distracted with approaches that are time consuming and sloppy and so it's no wonder that they are falling short. 

We are trying to invent a wheel and right now we are at the sqaure rock on an axle stage but things look good going forward. We are in the midst of a creative time.

Lowell 

 Scott,

First, welcome to EMR Update, I'm glad to see you here. 

I commented on this NEJM article earlier. Dr Groopman and Dr Hartzband are a husband/wife team who strongly influenced my medical education as a resident and fellow. (In fact, Pam Hartzband taught me how to do thyroid FNA's, Jerry taught me a lot about HIV and compassion at the same time.). Both are excellent clinicians and wonderful teachers. They obviously can call them as they see them.

Your comment on MDs as CIOs was spot on. It is curious that the CIO at the same institution as Drs Hartzband &  Groopman,  is the widely read MD blogger John D. Halamka.

Thus the current suboptimal implementations exist even in MD oriented institutions.

Yet it is my contention, and probably yours, that the current poor state of affairs is probably from a lack  of MD input rather than too much.  In our 20 doctor office, we feel we are ahead of the curve as far as note quality and efficiency. And that is because we have no IT people calling the shots. Yes, we have IT people, but no they don't call the shots. We also don't have any nurses or administrators calling the shots either.

Because the planning, and most importantly the responsibility, for implementing electronic records is so diffuse, we often see a lousy result. A camel is a horse designed by a committee. An in the hospital arena, they are often designed by a committee who doesn't even understand horses.

 

Good to see you here, and I hope you'll be back. 

(And 73 from KC5JIF - available for a sched....)

 Reddy Biggs MD

Your comment on MDs as CIOs was spot on. It is curious that the CIO at the same institution as Drs Hartzband &  Groopman,  is the widely read MD blogger John D. Halamka.

Dr. Halamka is so very in tuned.  I link to his blog on the Medical Quack and well as Paul Levy's blog, the CEO of Beth Israel in Boston, who is also kind enough to link to my site.  

Just this week Dr. Halamka was on Dr. Anonymous's Blog Radio, and there's also a link on my blog to find it.  You can revisit the link and listen to past broadcasts and download them as well.  His presentation was by far one of the best!  I sat in the "peanut gallery" chat room, whereby listeners can text messages back and forth during the presentation and ask questions as well.  He addresses right up front the mistakes that many have made in not involving the physicians in the process, and specifically the UCLA failure of a few years ago.  

It was interesting to listen to him speak and hear that he has roots back to California as well.  In the past I also participated and listened to the presentation by Paul Levy as well.  Dr. Anonymous is a physician that has been running the radio broadcast and everything is pretty informal.  If you listen to the broadcast, Dr. Anonymous starts out filling in time discussing what is on schedule for the broadcast and Dr. Halamka starts about 10 minutes or so in the broadcast.  

 http://www.blogtalkradio.com/doctoranonymous

 Usually every week I announce the broadcast on the blog as I did this week.  Dr. Anonymous also has his website and the Medical Quack has been a runner up on the Red Scrubs weekly award for blogging as well and the site has some pretty good additional information as well.  If anyone sees anything worth nominating, they do an award every week so I'm still working for those red scrubs so I can do the next oovoo video properly attired.

http://redscrubs.com/category/popular-medical-stories/scrubby-awards/

 > Yet it is my contention, and probably yours, that the current poor state of affairs is probably from a lack  of MD input rather than too much.

Indeed, I see lack of physician input and lack of physician leadership - especially by physicians fluent in IT and those who've had formal postdoctoral medical informatics training - as a root problem of HIT difficulty.  I make the case in the opening essay at my website at http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm .

A Powerpoint presentation of my own, given to the IEEE Medical Technology Policy Subcommittee late last year, might also be of interest, on the lack of resilience engineering (their term) in clinical IT:

To the Moon in a Hot Air Balloon:  Why Clinical IT is Difficult   (zipped pdf file).

  

 

-- SS

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