A Day In The Life Of A (Reluctant But Coerced) EHR-Using Physician - And Her Patients

A reader, a physician who wishes to be unnamed due to fear of retaliation, writes the following:

Dear Dr. Silverstein,

As you write, there is not a transaction of medical care that does not go through EHR systems.

However, these poorly usable EHR systems stifle creative and artistic thought required to link risk, benefit, and probability of diagnosis with risks and benefits of testing and therapeutics.

Assuring safety and efficacy with pre- and  aftermarket surveillance will maximize the possibility of achieving the potential of the technologies.

Additionally, when I use these electronic ordering systems and  libraries of medical information, they fail to keep up with the agility and nimbleness of my mind as I seek 'random access' to pieces of data to formulate and synthesize diagnoses and therapeutic strategies.

The EHRs are too slow, do not have a robust (if any) search function, randomly and whimsically store key information with ever changing formats, and generally obfuscate what should be simple. They are cumbersome and disable the ability to simultaneously and contemporaneously compare myriad data points.

They get an "F" as enablers of complex diagnostics.

Paper, since it can be organized as needed and set out on a desk to be seen and compared as quickly as the eye registers the data, gets an "A".

The EHRs  are impediments and disrupters of communication.

Example: Just today, I was witness to the fact that a stat EKG was ordered by CPOE  on a heart patient yesterday at or shortly after 4:30 pm. The intended recipient of the order (heart station) never got it because they close near 4:30 pm and there was no warning to the ordering health professional that was so.

Thus, the EKG was never done, and this morning, when the requisition was seen, no one did it because it was ordered stat "yesterday", and the techs asked themselves "what good would it do for a 'stat' to be done now, a day late?"

I do not know what happened to the patient.  I have many other examples of such delays facilitated by the CPOE and EHR systems that I am required to use at numerous facilities.

They facilitate 'stealth' alterations in care.  Also just today, a disease-critical test ordered 3 days ago was not done because it was cancelled in 'stealth' (automatically "expired") without warning to me by the lab responsible for doing it.

There is the "silent silo" syndrome as you've called it.  Also just today, a disease critical test ordered 5 days ago came back with results, but the results were posted in the information 'silo' of 5 days ago. The lab screen default on the EHR only goes back 4 days (so unless I knew to look for it, it would not be seen or acted on), further obfuscating data and delaying treatment.

The EHRs lose data and orders.  Also just today, I found that blood coagulation monitoring tests that were ordered to be done with kidney dialysis (3 days per week) on a patient somehow got "lost" and were not being done for 5 days, putting my patient at risk of bleeds - or stroke if the blood was not 'thin' enough.

I just walked in to examine a hospitalized patient with multi-organ failure and diabetes, on multiple meds including insulin, and recovering from respiratory failure.

The nurse anxiously informed me that the blood sugar was dangerously low. I ordered treatment stat.

I see patients in the morning before labs come back, and depend on nurses to review labs and notify me.

Turns out that the patient was hypoglycemic on yesterday morning labs that arrived in the EHR 'silo' after I left the hospital; and was also low in potassium, but the tests just laid there comfortable in their silos; and were not communicated to anyone like in the old days when a human ward clerk or other undistracted human received them and disseminated them to the appropriate professionals.

Thus, instead of getting less insulin, the patient got the usual dose with near catastrophic adversity.

Misidentifications are facilitated by EHRs.  I  noticed that on several critical clinically significant changes that arose on my patient that were entered as such in an EHR silo by the RN, it was stated that they called attending physician 'Dr X', which was not me...obviously a case of EHR-facilitated misidentification.

Here is a misidentification variant:  yesterday, someone (non doctor but not clear who) ordered a specialist consultation on one of my patients under my name. I did not order it nor was it needed, yet it showed up as an order for me to sign.

Like you, I agree this is representative of a toxic impact of these systems on medical care and I feel like the care environment is foul, like a cesspool, compared to what has been replaced.

These systems of medical devices cannot be trusted in the care of sick patients. Perhaps, they are OK for managing hang nails.

I offer no additional comments other then if I am sick, I do not want my care interfered with in this manner by IT.

Rest assured, though - there are IT hyper-enthusiasts out there (http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html) who would see little problem with this, as any accidents that occur are "anecdotes", "learning experiences" or "bumps in the road."

That's if they don't simply blame the user.

-- SS

WaPo: "When treating a patient with dementia, electronic health records fall short"

Which raises the question:  for what patient types do EHRs in 2014 not "fall short" in many of the ways cited by this author?

When treating a patient with dementia, electronic health records fall short
By Regina Harrell and Pulse
December 23, 2013
http://www.washingtonpost.com/national/health-science/when-treating-a-patient-with-dementia-electronic-health-records-fall-short/2013/12/20/7bb51b34-416d-11e3-a751-f032898f2dbc_story.html

I am a primary-care doctor who makes house calls in and around Tuscaloosa, Ala. Today my rounds start at a house located down a dirt road a few miles outside town.

... We chat about the spring garden and the rain, then we move on to Mr. Edgars’s arthritis. Earlier on in his dementia, he wandered the woods, and his wife was afraid he would get lost and die, although the entire family agreed that this was how he would want it.

... We talk about how anxious he grows whenever she’s out of his sight and how one of his children comes to sit with him so that she can run errands.

The omitted lines of this physician's encounter are poignant.  Read them at the Wash. Post link above.

... When I get back to the office, I turn on the computer to write a progress note in Mr. Edgars’s electronic health record, or EHR. In addition to recording the details of our visit, I must try to meet the new federal criteria for “meaningful use,” criteria that have been adopted by my office with threats that I won’t get paid for my work if I don’t.

The "meaningful use" criteria, I point out, are an unproven experiment, decided upon by committee.   They are not evidence-based.  Physicians are, in effect, being threatened with nonpayment as part of the experiment.  They have become experimental subjects themselves, for free, and without true informed consent.

Under “History of Present Illness” (HPI), I enter “knee pain.” Up pops a check-box menu: injury-related (surely the chronic wear on Mr. Edgars’s knees from his work as a farmer is some sort of injury, but I don’t think that’s what the computer programmer had in mind), worsening factors (I know of none that apply, since he couldn’t give his own history), relieving factors (there’s no check box for a tired, sleep-deprived wife who’s purposely keeping the dose of acetaminophen low) and so on. Nothing fits, so I exit the HPI and type in “follow-up” (f/u), for which my EHR doesn’t have a pop-up menu. It yields only a blank screen.

As a medical student, I was forbidden to use paper templates to "remind me" of what I needed to record in an H&P or progress note.  The "table of contents" had to be learned and applied from memory.  The continued patronization of physicians, nurses and other clinicians via templates like this, and the resultant de-skilling, time-wasting and other deleterious effects, is harmful to quality care.  This physician comments later that without EHRs and "meaningful use," she could see twice as many patients.

I type the Edgars’s story in my own words, so different from the computer-speak generated by the check boxes. I move on to the Review of Systems — another pop-up menu.

Translation:  handwritten or typed narrative is meaningful; computer-generated prose is largely "legible gibberish", i.e., garbage.  I note that the EHR output in a recent ED visit of my own would have received a failing grade for documentation quality when I was in medical school - and I would have had serious words with a trainee who'd written such sloppy prose when I was a senior resident and attending.

I used to simply write “patient is an unreliable historian” at the beginning of this section, but the computer doesn’t understand that this statement could apply to the entire review.  [Actually, the designers and programmers who believe they are "revolutionizing" the field didn't understand the real world of clinical medicine - ed.] Using a template, it generates a page of 13 sentences, one for each body system, and, under each sentence, the option “Positive: Other: unreliable historian.”  [Which much then be clicked 13 times - ed.]

Sometimes I wonder if it is disrespectful to a patient to say 13 times in one progress note how unreliable a historian he or she is, but I remember that this is great data to mine for research, so I plug on.

This is not just "disrespectful", but a waste of clinician time.

Under “Physical Exam,” there is a template for geriatric patients. I pretend that the computer-speak it generates creates logical sentences, although I know better. In the check boxes, a person can be oriented to person, place and time, or not. Mr. Edgars is oriented to person and place; he knows that he is with his wife and at home, and is happy nowhere else. He no longer cares what year it is. There isn’t a check box for that.

Obviously this "feature" was not even run by medical students, who know that orientation is not "x3" or "none" as the only pertinent options.

Technically speaking, this represents inadequate and insufficiently granular data modeling ... a task I wrote years ago that requires the highest levels of clinical and biomedical informatics expertise, not computer or programming expertise.  There are likely many other examples of poor data modeling in this EHR.

I remember that I must go back to “Social History” and document tobacco use. It occurs to me that if you have not tried tobacco products by your 80th birthday, you are unlikely to suddenly change your mind. Especially when you can’t remember where the store is to buy them. So I slog through the series of check boxes for “never smoker,” an extra six mouse clicks.

More wasted time.

After 15 minutes, the note is finished. And on goes my day of house calls, five in all.  There aren’t enough physicians to see all the homebound patients in my area, so I try to visit as many as I can safely care for.

At day’s end, I review my meaningful use.  I spent more time checking boxes than talking to patients and their families.

I could see twice as many patients if I could write their notes at the bedside while visiting with them.

In other words, in this underserved area in and around Tuscaloosa, Ala., the "meaningul use" of EHRs deprives homebound patients of care.

I would happily do this on paper or using an EHR that created a logical note within the same amount of time. But that is not an option.

Such EHRs are rare, if they exist at all.  Besides, this physician is likely contractually bound to use some larger organization's choice.

The reality is that I spend more time talking to the Information Technology people about Internet connections, firewalls and box-checking than I do answering messages from concerned family members.

In other words, computerization is in the way of the best practice of medicine.

As a teaching doctor, my feedback to the residents now consists mainly of explaining how to document their visits so that we will all get paid, instead of teaching them how to take care of frail elders in their homes.

I remember my community medicine clerkship in the early 1980s in a relatively underserved region in Maine.   Other classmates at Boston University School of Medicine did similar clerkships in Roxbury, an exceptionally poor and harsh section of Boston near Boston City Hospital.  We were taught patient care...with nothing less than the patient's best interests at heart.  Medicine today is now being financially and cybernetically deprived of its heart and soul.

 

I believe I can honestly say the EHR here contributed nothing to the care of this patient, and was deleterious to the overall clinical mission for this patient, and for others.

Harrell is a geriatrician and assistant professor of family medicine at the College of Community Health Sciences, University of Alabama. This is an edited version of a story that originally appeared in Pulse — Voices From the Heart of Medicine, an online magazine of stories and poems from patients and health-care professionals.

I hope that patients who are not suffering dementia will increasingly take notice that these systems are depriving them of their clinicians' attention and of providing good documentation for their future care.  

 

Clinicians themselves, with the exception of some unionized nurses, have grown largely complacent about bad health IT, the "meaningul use" experiment and IT's getting in the way of medical care to feed the bureaucracy.

-- SS

 

Jan. 15, 2014 Addendum: 

 

The reader comments at the original story in "Pulse" magazine are worth reading, and are at the bottom of this page:  http://pulsemagazine.org/archive/stories/310-checking-boxes

-- SS

"Doctors' Dissatisfaction With EHRs May Be Early Warning of Deeper Quality Problems" - And Some Common Sense on EHRs and Clinician Distraction and Time-Wasting

The following article was published regarding physician dissatisfaction with EHRs, referencing a RAND study on EHRs commissioned by the American Medical Association:

http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0

Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems'
October 18, 2013 - 10:17 AM
By Susan Jones

Electronic health records (EHRs) are a source of frustration to many physicians, says a new study conducted by the RAND corporation and commissioned by the American Medical Association.

Electronic health records are a source of frustration to many physicians, according to a study on physician satisfaction sponsored by the American Medical Association.

The findings could serve as an "early warning of deeper quality problems developing in the health care system," the AMA said.

The study, conducted for AMA by the RAND Corporation, found that doctors who perceived themselves or their practices as providing high-quality care reported better professional satisfaction.

Electronic health records (EHRs) were a source of both promise and frustration, the Rand study found.

Although physicians tend to like the concept of EHRs, those surveyed said that current EHR technology interferes with face-to-face discussions with patients; requires physicians to spend too much time performing clerical work; and degrades the accuracy of medical records by encouraging template-generated doctors' notes.

I believe the title should have been "Doctors' Dissatisfaction With EHRs Is A Warning of Deeper Quality Problems".  The academic-style fudge words "may be" and "early" are disposable.

"Physicians [i.e., all of them - ed.] believe in the benefits of electronic health records, and most do not want to go back to paper charts," said Dr. Mark Friedberg, the study's lead author and a RAND scientist. "But at the same time, they report that electronic systems are deeply problematic in several ways. Physicians are frustrated by systems that force them to do clerical work or distract them from paying close attention to their patients."

Dr. Friedberg commits a faux pax symptomatic of an amateur scientist (or of a politician).  That is, making a statement that seems to speak for all physicians, and then for "most" physicians.  Clearly he didn't interview "most" physicians.  I know many who see the EHR as bureaucratic invasion of little clinical utility, and would gladly dump the poorly-engineered EHRs foisted on them that "interfere with face-to-face discussions with patients; require physicians to spend too much time performing clerical work; and degrade the accuracy of medical records" for good old-fashioned paper, supplemented perhaps with document imaging systems that make the notes available anywhere, anytime.

... Health and Human Services Secretary Kathleen Sebelius has said that EHRs will lead to "more coordination of patient care, reduced medical errors, elimination of duplicate screenings and tests, and greater patient engagement in their own care."

Sebelius is parroting others; there is little or no robust evidence supporting such a grandiose assertion (or, typical of today's politicians, she's simply lying; the reader can decide which).

For 2014, some commonsense observations and recommendations on EHRs:

1) The pioneers in the 1950's and 1960's developed systems and experimented with their use in an environment far freer of the bureaucratic need for massive amounts of ultra-taxonomized data than today, where visits were not forced to be time-limited for "productivity", and where clinical notes were pithy and terse, as they were for patient care, not bureaucratic satiation.  The pioneers likely could not have conceived of what clinicians are being called on to enter manually, in 2014.  (I was taught Medical Informatics by some of those pioneers.)

2) The pioneers never intended to add uncompensated burdens onto clinicians.  They intended to help clinicians practice medicine more smoothly, not in a time-starved and robotic, slave-to-the-machine fashion.

3) The health IT industry and its health IT designers, and the largely medically-incompetent data processing/merchant computing personnel in hospital IT departments, appear to have not cared less about these real-world HIT issues - as evidenced by their products - until the pressure was put on by users, resulting in studies of IT safety by the Institute of Medicine (http://hcrenewal.blogspot.com/2010/10/cart-before-horse-again-institute-of.html) and of IT usability by NIST (http://hcrenewal.blogspot.com/2010/12/nist-provides-healthcare-it-industry.html) in just the past few years.

With these factors in mind:

... AMA noted that some medical practices are experimenting with ways to reduce physician frustration by hiring additional staff members to perform many of the tasks involved in using electronic records, such as data entry.

Actually, the use of clinicians as computer data-entry clerks was the real experiment, an experiment whose failure is becoming increasingly apparent. 

The "experiments" with hiring of data entry clerks should be made official healthcare policy as follows: 

1)  Physicians and nurses should be relieved of the burden of data entry into computer interfaces (as opposed to merely viewing) nearly entirely.  Data entry cannot be done under the real-world conditions of patient care in 2014, for most specialties, without compromising the focus on patient care (let alone clinician morale).  

2) Considering the hundreds of millions per organizations spent on theses systems, a pool of data entry clerical staff can well be afforded, hired and trained to transcribe data into computers from clinicians' paper notes, using specialized forms where necessary.  

3) Those same paper notes can be rapidly imaged into a document management system (e.g., Documentum, http://www.emc.com/enterprise-content-management/documentum-platform.htm; I managed a pharmaceutical department of ~55 people and a $13 million budget using such a system) and made available before transcription.  The note images can also serve as a supplement to data viewing screens in the EHR, which at least in 2014 are themselves poorly engineered from the perspective of optimal presentation of information.

4) The workflows for such arrangement are known to me; I created such an environment in a busy invasive cardiology department, a critical care area performing more than 6000 procedures/year and responsible for 25% of the organization's revenues - fortunately having been able to neutralize and marginalize an IT department seemingly hellbent, perhaps through ignorance, on sabotaging the effort.  See "Essential Value of Medical Informatics Expertise in High-Risk Areas: an Invasive Cardiology Example" at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story.  The offloading of data entry by clinicians into the computer, and the use of special paper forms for the clinicians, worked exceptionally well in allowing the clinicians to focus on what really matters most - patient care.

5) If healthcare organizations insist on direct clinician data entry, then clinicians' time doing so should be fairly compensated.  Lawyers generally earn from $250/hr and up for profession-related clerical work, like creating legal briefs and letters.  I think physicians should do at least as well.  (If readers believe clinicians should take on this considerable burden and not be fairly compensated, I'd like to hear why.)

6) If healthcare organization leaders truly believe the EHR hyper-enthusiasts, the expense of the clericals will be far offset by the "billions and billions" saved by these systems.

       a) If they don't believe the EHR hyper-enthusiasts, they should be far more skeptical of implementing such systems and imposing the mission-robbing burdens on their clinicians in the first place.

7) These measures will free industry resources for doing what really matters most in clinical care, namely, health IT robustness (freedom from error, security, etc.) and optimal presentation of information customized for the needs of the many different clinical specialties and subspecialties.

-- SS

On Hypervigilance Due to Bad Health IT: "Texting While Doctoring: A Patient Safety Hazard"

An Opinion piece "Texting While Doctoring: A Patient Safety Hazard" appeared in the Annals of Internal Medicine of 3 December 2013, authored by Christine A. Sinsky, MD and John W. Beasley, MD.  Dr. Sinsky is known to me to be what some would call a "heatlhcare IT iconoclast" (more accurately represented by the term "healthcare IT gadfly/realist" IMO).

In the piece the authors comment on the distractions caused by the technology, leading to doctors missing important cues in the exam room and to and impaired problem-solving.  This is part of a larger phenomenon that has been called "skill-degrading" or "de-skilling", e.g., see my April 16, 2010 post "Health Information Technology Basics From Calif. Nurses Association and National Nurses Organizing Committee" at http://hcrenewal.blogspot.com/2010/04/health-information-technology-basics.html).  

These effects are likely to be further worsened as more and more clerical tasks such as order entry, the authors point out, get shifted to medical professionals.  To new readers: note that computerized order entry is often a complex and convoluted process; the CPOE systems are most decidedly NOT mere "typewriters for orders."  See, for instance, part 6 of my series on "Mission-hostile health IT" at http://hcrenewal.blogspot.com/2009/02/it-makes-healthcare-easier-is-this.html.

Most of the Annals article is available as a free preview at http://annals.org/article.aspx?articleid=1784295 as of this writing and is worth reviewing.

Article preview, click to enlarge

I found one passage in particular striking, though.  In my ongoing discussions with computer scientist/informaticist/polymath Dr. Jon Patrick at U. Sydney (http://www.healthll.com.au/?page_id=440) , the issue of hypervigilance necessitated by bad health IT came up, and we arrived at the definition of same seen at my teaching site at http://cci.drexel.edu/faculty/ssilverstein/cases/:

Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation. 

Note this passage in Dr. Sinsky and Beasley's opinion piece:

"I am always multitasking ... I am entering orders, checking labs, downloading information while I talk to the patient.  It requires chronic hypervigilance, which is exhausting and demands conscious effort to stay in the 'present' with the patient" (Day S., Personal communication.)  Click to enlarge.

I don't know if Dr. Day had seen my materials, but I suspect the exhausting hypervigilance is all too common, just not much publicized due to the secretive, closed, retaliatory-towards-whistleblowers nature of the healthcare IT sector.

I ask:  is this what we really want, in pursuit of some uncertain cybernetic miracle?

I note that the healthcare IT experiment (and the technology is experimental), long usurped from the Medical Informatics pioneers who trained me and put in the hands of commercial interests and those of a mercantile/manufacturing/management computing background, is increasingly a failure.

-- SS

Should "Diagnosing While Texting" Be Illegal?

I saw an interesting comment at Medscape in the comment thread of the article "Do Your EHR Manners Turn Patients Off?" (MedScape subscription required).

Dr. [redacted] | Neurology

I live in a town that has passed legislation criminalizing texting and driving. A driver is more impaired and distracted when texting than when intoxicated.  EHR's and the practice of medicine should be no different. Do you really believe that your physician is actually concentrating on the patient in front of them while their attention is primarily focused on entering data on a computer? The reality is that EHR's true value is data collection for statistical analysis by our government and there is an obvious deficiency for enhancing the physician-patient collaborative experience.

Medicine, like driving, is a very cognition, thinking and concentration-intense activity.   Failures lead to injury and death (although not quite as dramatically in the former compared to the latter).

I think the point about distraction the commenter makes is valid, or at least worthy of healthy consideration.

Unless you're a health IT hyperenthusiast, that is (see http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html).

-- SS