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I would like to ask why is it that the younger and older doctors and all between are rejecting this technology as to slow to use during patient visits.
There are some specialty and physicians that love this technology. There is a growing number more that have gone through 3-5 implementations of EMR with no success. They obviously get it, they have trained on it 3-5 times.
Many of these guys watch this forum.
To these guys, young and old, technologist to producer, and all points in between I ask this question. I would prefer if this becomes a Physician interaction, but Surely vendors like myself will chime in.
Lurkers and Doctors with experience on this please chime in, I implore you.
Brendon
Time.
Everyone seems to want more of my time. My patients, my staff, my wife, my kids..... Nobody gets enough of it.
And now I must use an EMR that takes more time to document than checking off boxes from the handy little forms I printed up 15 years ago?
I must spend time researching which is the best fit for my practice.
I must take the time to learn this system, and see fewer patients while I do so?
Doctors starting new practices have a higher adoption rate, despite the costs, since they have spare time on their hands. They see the EMR as an innovation that can make their practice stand out as being more up-to-date.
Until there are stronger incentives (and not unfunded mandates) to persuade existing doctors to convert, adoption will be painfully slow.
So why did my group take the time to adopt an EMR?To save time.
The time benefits with EMR adoption don't exist in every product. Even in EMRs that do allow time and efficiency improvements, it is not obvious to non-users. My collegues don't recognize that I am seeing 20% more patients this year than last, yet get home for dinner on-time more often. All they know is that I can see more of their referrals, and the wait time for a new consult appointment has dropped. At home, when I get a patient phone call, I can look at the record in no time.
In essence: The time costs to EMR implementation are obvious; the time savings are far from obvious.
Thus, a rational thinker would thus avoid EMRs, unless they can look beyond the obvious.
Reddy Biggs, MD
William "Reddy" Biggs, MD
Managing Partner, 23 physician Internal Medicine group
"Live on eClinicalWorks since 2/1/2007" http://tinyurl.com/reddybiggs
I think you answered your own question...its too slow.
There are disparate things that we are asking EMRs to do and they can't do all of them well. Note taking is one that seems to be too slow. Organizing labs is one they do well. It may be that the EMR states it can do all things well (trying to appease the customer and make a sale) but the user senses it can't and then rejects the technology.
This is my situation. The EMR stated it was able to do x,y,z and while it does these things it does not do them efficient enough. But, I don't necessarily see it as a flaw of the EMR. It's is trying to do what the medical system (insurance co's, P4P, etc.) is asking it to do. It will eventually do these things better than its current approach, but it will always be a bother as long as we have to have an accounting system as part of the measurement of what we do. Another example of business tactics being errouneously applied to medical offices??
If the insurance company abandoned the accounting aspects of what they ask of us I think EMRs would look different. I think capitated healthcare offers an opportunity in this regard.
Lowell Kleinman, MD www.drkleinman.com www.old-fashionedhousecalls.com
Repost from another thread:
Brendon: I happen to know many Med Students that when they leave Med School within the last few years came out excited as hell about EMR, many of which have use multiple EMR's in the hospital setting. They cannot wait to use it in practice. When they get there, these Blackberry touting, Google brilliant computer generation kids come up with the same conclusions as there fathers that have tried this technology and rejected it already, at a cost of $200K plus for a 6 physician office. There conclusion follows there fathers: EMR's allthough when properly installed often create great office efficiency, but often at the cost of Speed and Ease of Use for the End Physician, who now is fundamentally changed from a Patient Doctor visit relationship to a Data Entry Clerk. Doctors do not have time for this.
I happen to know many Med Students that when they leave Med School within the last few years came out excited as hell about EMR, many of which have use multiple EMR's in the hospital setting. They cannot wait to use it in practice.
When they get there, these Blackberry touting, Google brilliant computer generation kids come up with the same conclusions as there fathers that have tried this technology and rejected it already, at a cost of $200K plus for a 6 physician office.
There conclusion follows there fathers:
EMR's allthough when properly installed often create great office efficiency, but often at the cost of Speed and Ease of Use for the End Physician, who now is fundamentally changed from a Patient Doctor visit relationship to a Data Entry Clerk.
Doctors do not have time for this.
I've been in practice for 2 1/2 years. That description fits me! I started looking at EMRs back in 2001. And is the reason I'm here at EMRupdate still looking for an EMR that doesn't crimp my paper based speed and patient interaction and doesn't put me into bankruptcy.
I'm narrowing down to Brendon's eMedRec ( but would have to take out a multi year bank loan to make the purchase) or use Graham's Synapse which he is improving the paper import utility, or buy another filing cabinet.
The perfect scenario would be to use my paper form digitally and to easily see past visit notes to visualize pain diagrams. Waiting to see how well Murdoch's secret inking app integrates with Synapse. That way I wouldn't have to deal with both paper and an EMR. eMedRec is premier but doesn't fit my solo practice budget at this time, along with the added yearly 15% fee.
Reddy -- A gold star post that deserves preservation, publication and publicity.
Robert (get your hat) and I shall arrange an all-star Shakespearean production of your comments to reinforce the principle that "EMR saves time".
Well said Sir!
Nick
Nick Harrington email me or Skype: nickharrington emrupdate.comIf I have seen further it is by standing on the shoulders of Giants" Sir Isaac Newton 1676
#1) EMRs are not needed.
If you believe they are needed, then the #1 problem is Cost.
email:
More than likely they have been told a bunch of unverifiable statements by salesmen.
There are a few people like Reddy who see more patients than before, but the EMR is a tool, and you have to find time to master it. Most do not.
If I look at an EMR, I see some things that take more of my time than before, and other things that take less.
Less Time
Overall the time taken is much less than before.
I'd suggest new users analyse their EMRs and use it for those things that reduce your time, and then when well trained, start to work on the other more time consuming aspects
( actually documenting is faster now on the EMR because my handwriting is no longer legible since I haven't written by hand for 15 years now )
Graham http://www.synapse-ehr.com/ Synapse - the EMR for the superior physician
Some facts, philosophy, and metaphors here.
So, this chronic EMR rejection by young and old sounds mysterious?
It's been said there are no mysteries. Only false assumptions.
From my perspective (Medical Informatics, formal postdoc in same) there's been vastly inadequate involvement in design and implementation by medical/IT professionals who actually studied as hard as any other medical subspecialty in how to do EMR "right."
In a nutshell, EMR and other clinical IT projects are complex social/medical projects in unforgiving clinical environments, to create virtual clinical tools that happen to involve computers - NOT computer projects that happen to involve clinicians.
When you proceed from the latter assumption as opposed to the former in terms of leadership selection, talent management, systems design, etc. --- you get what is expected. The failure rates of all IT are not stellar, but when you start out with false assumptions, it only gets worse. See:
Statistics on IT Project Failure Rates. The surveys referenced here provide statistical data regarding IT project failure rates. This topic is not often discussed in the mainstream IT literature. Health care IT failure rates may be even higher due to its greater sociotechnical complexity compared to traditional business IT. link
and
Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT that should be read by every healthcare executive documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT. link to pdf
Most vendors and hospital IS departments have little clue what the field of medical informatics is about. They believe clinical IT is just another breed of management information system. They're wrong. Clinical computing and business computing are two different subspecialties of computing, much as psychiatry and neurosurgery are different medical subspecialties - even though on the same body part.
Yet, try to use a scalpel to cure a neurosis, or psychotherapy to cure a brain tumor, and you get bad results. Try the approaches of business computing (rigid systems lifecycle principles, poor customer focus, aversion to agile methodologies, belief that the processes of clinical care can effectively be "modeled" as business processes, etc.), and you get bad results. For a great short article on the latter point, see Hiding in plain sight: What Koppel et al. tell us about healthcare IT. Christopher Nemeth, Richard Cook, J Biomed Informatics 2005 Aug;38(4):262-3 (link to pdf).
Yet with all this, Medical Informatics professionals and other computer-proficient physicians have a hard time being suitably engaged in HIT. See for example this lovely story. It's mine personally, and one of many.
Let me ask the reverse question:
When the HIT industry treats clinical IT as just another breed of management information system, why would anyone expect it to work out well?
-- SS
Older, sicker patients on multiple medications, new tests, more frequent monitoring, more diagnostics. Polypharmacy is the rule, not the exception. This in the face of declining reimbursement, increasing overhead and a growing scrutiny of quality, outcomes and satisfaction.
Yet adult medicine physicians are trying to see 30, 40, or 50 patients a day (and some are also 'supervising' a PA/ANP at the same time).
Many aren't doing a good job on paper - is it any wonder they can't tolerate 30 seconds longer to order a test or prescription? Why they don't want to do medication reconcillation even in the face of unacceptably high outpatient drug error rates? Why some patients have a consultant for every organ system and fragmented, disorganized medical care?
Now, I know that the above couldn't possibly apply to the faultless work done by the members of this board, but it might explain why many highly stressed practices can't get an EHR to increase their income - and that's the only reason to use one, right?
Despite Dr. Silverstein's tireless criticism of HIT, there are adequate EHR's that will increase your ability to practice high quality care and at the same time remain reasonably productive. The glass is at least half full if you are interested in drinking.
Inability to understand workflow, or non existence thereof and quality control.
Longitudinal documentation is so poorly understood and sometimes perceived as redocumenting with a single click is a form of cheating wherein fact the subconscious mind do register such information to facilitat formulating an impression. Much of what we do thru a patients chart is redundant yet we deny or do not see it.
Inconsistency - have anyone analyzed their own or within a practice approach? Why would one problem be approached differently or vary somewhat on dfferent times of the day or week.
Attitude/cultural change - we make excuses and indoctrinated to resist change. Traditionally the academic field are staffed mainly by private practitioners that educate the new generation of both the science and art of Medicine. The bookish approach of the more venerated academicians, I wonder if are capable of surviving and competing in the real world practice of medicine, removed from the over rated endowment of the title "professor". The art have been methodically eliminated and disguised to a narrow boundary of the practice of medicine to "evidence based", at the convenience and financial gain of the 3rd party payors. The eventual elimination of - off label use, will soon eradicate further research / studies = evidence based, investigations of assumptions. This finite approach is reflected by our attitude/culture rejecting the digital world. Yet 100% I presume of the same target audience rejecting this technology uses a computer! Go figure.
> Despite Dr. Silverstein's tireless criticism of HIT, there are adequate EHR's that will increase your ability to practice high quality care and at the same time remain reasonably productive.
You're perhaps jumping to unwarranted conclusions on my views. I agree there are adequate EHR products and maybe some 'excellent' ones too for small and group practices, and for larger enterprises. I've led the successful implementation of enterprise EMR at a regional medical center where I was CMIO. However, it took extensive due diligence and a product and culture that (ultimately, with a bit of coercion and arm-twisting) allowed clinician-led, specialty-specific customizations to occur.
My issue is that there are adequate EHR's, but in a sea of mediocre products that healthcare can ill afford. Physicians and hospitals should not be the the R&D arm and alpha/beta testing sites for clinical information technology when the reasons for IT failure and difficulty are well known via an ever-growing body of empirical research. Social informatics is one field that specifically studies these issues. However, there are scant people in IT/IS/SE who've ever heard about that field or, when they do learn of it, take it seriously. As I have both worked in hospital and pharma IT, and teach grad students in those fields, I have witnessed resistance to such material firsthand.
> Attitude/cultural change - we make excuses and indoctrinated to resist change.
Clinicians are asked to "change their culture." Where are the calls for reciprocal changes in IT culture that would result in optimal products as the rule rather than the exception, less waste of time and resources, less clinician frustration, less problems such as at Bad Health Informatics Can Kill?
As part of an NSF-funded IT Workforce grant, the authors conducted ethnographic research to provide deep understanding of the learning environment of computer science classrooms. Categories emerging from data analysis included 1) impersonal environment and guarded behavior; and 2) the creation and maintenance of informal hierarchy resulting in competitive behaviors. These communication patterns lead to a defensive climate, characterized by competitiveness rather cooperation, judgments about others, superiority, and neutrality rather than empathy.
Why did I have to (unsuccessfully) fight IT personnel about hanging CPU boxes from the ceilings of ICU's where the dust and crud that accumulated in them was an excellent medium for colonization by airborne pathogenic organisms that are common in ICU's, to be spread by the power supply cooling fans to the next occupant?
Why do I hear similar stories of HIT dysfunction from my informatics colleagues and from my students, many of whom manage clinical IT in their hospitals?
Can anyone provide me a reasonable explanation for why such events occur?
scotsilv: Can anyone provide me a reasonable explanation for why such events occur? -- SS
Lack of foresight, fiscal concerns, improper training contribute but perhaps greatest of all is a lack of examples of tremendous success. For sure they exist but failures are everywhere...catch 22 in that regard.
> Lack of foresight, fiscal concerns, improper training contribute
I'd place arrogance, not knowing what you don't know, not caring that you don't know what you don't know, cavalier attitude about patient care, and lack of accountability higher on the list as to why I faced these obstacles. The CIO involved has moved on to an even bigger hospital as the reward.
The head of the ICU and the Sr. VP for Medical Affairs deferred to the IT personnel as if they were some sort of all-knowledgable oracles, a symptom of physician learned helplessness [Bond C. The training of the "helpless" physician. Medscape General Medicine 2007; 9(3):47].
That deference is one of the causes as to why HIT in large part is so awful. This MUST change.
Physician learned helplessness
Medical training is inculcating a culture among physicians that may be deepening their woes and contributing to the decline of the profession.Helplessness can be trained into individuals when, regardless of repeated best efforts that should be rewarded, no reward is forthcoming; as a result, the individual eventually learns to give up and sinks into a lonely feeling of futility and malaise. It would appear that collectively the medical profession has mastered this art and is suffering the symptoms en masse.Unfortunately, medical training is helping to create the foundation for the profession's helplessness. Regardless of the new limitations on work hours, conditions in many training programs remain reminiscent of medieval, monastic, ascetic orders. Self-deprivation -- especially sleep deprivation -- continues to be viewed as a necessary virtue, especially during subspecialty training. Learning is still most often imposed on the basis of the model of strict authoritarian discipline, with a high degree of emphasis on shame and fear of failing. Good patient care is so expected of trainees that it is rarely rewarded. Residents' pay is usually set at bare subsistence levels or below, so there is no financial reward for the hard work of medical training, and indeed most medical graduates emerge with huge school loan debts.Psychologically, young physicians often expect residency and fellowship to be the crowning experience of their long educational path. Since they were 5 years old, these young people were told that they were the brightest and the best, a message that was socially reinforced as they successfully progressed through school, college, and medical school. Everything about their experience reinforced their belief in the Puritan work ethic: If you work hard and do well, you will be rewarded -- until they reach residency, a point at which rewards are so few and far between that they begin to believe that if they work hard and do well they will be resented.Young physicians become so well trained in deferring gratification that many give up on ever getting any meaningful rewards for their sacrifices. With their resilience worn away, many just give up the fight. A dispirited acceptance of one's individual fate seems to be the dominant mood of physicians nowadays rather than a motivated mobilization toward a better lot for the individual practitioner and the profession as a whole. Most doctors focus so hard on trying to provide good patient care -- ie, taking care of others -- that they forget, or have no energy, to take care of themselves. Thus, when some doctors propose positive collective action, they are usually quickly quieted by a few naysayers whose negativity taps into the helplessness learned so well during medical training. The progress of the profession is being effectively paralyzed by its own failure to teach leadership and the skills of self-survival.
Many doctors do not have a computer interest and only see the computer as an obstacle that they must learn & then feed just to get through their day. Many don't spend any more time on the computer than they HAVE to, and rather have their 13 year old look something up for them than try to learn to use the computer themselves. It isn't that they aren't capable, but they learned pen & paper from the beginning and that is the sytem that makes sense. And, even though many paper generated notes are illegible and take as much (if not more) time to generate/read/research/find as one in an EMR, it takes a lot of effort and training for some of these men & women to learn to navigate these environments. So, they just don'y do it.
As Reddy said it then becomes a "time" issue.
R Terry Ellis
DescriptMED, LLC
Get Done, Go Home!
Tour The Chart!
Terry,
You got me to thinking. I don't really believe it has as much to do with feeling at ease with a computer as it has to do with motivation. Our eldest Medtuity user is in his 80's and did not use a computer before Medtuity. He was willing to overcome those obstacles because he was motivated to have a paperless "office". Actually he does housecalls and did not want to even consider carrying files in his car in the NYC area. He was well-motivated to achieve his goals.
I think the real issue is the relative motivation to aggravation ratio. The motivation is not great but the purported aggravation is high. It is no wonder that adoption rates have declined.
The creation of Visicalc, for example, was one reason for the rapid adoption of PC's-- a new (and expensive) technology that had far more problems than today's computers, but that users were willing to overcome because the benefit was great.