EMR panacea under attack

I’ve argued here on Dr. Bobbs that EMRs are not ready for prime time for most practices and will not result in increases in efficiency or cost reductions for practices that are not ready for them, that is to say, most medical practices.  It appears I’m not alone in this assessment.  Brandi White at the American Academy of Family Physicians’ Noteworthy Blog:

Electronic medical records are being touted as an essential ingredient in health care reform. Most recently, the Obama administration proposed the national adoption of EMRs on the grounds that it would save $80 billion a year and improve the quality of health care.

But not everyone is drinking the Kool-Aid.

Drs. Jerome Groopman and Pamela Hartzband, faculty of Harvard Medical School (and, notably, both Obama supporters), recently called EMR adoption “an overly simplistic and unsubstantiated part of the solution” and had this to say in The Wall Street Journal:

“The basis for the president’s proposal is a theoretical study published in 2005 by the RAND Corporation, funded by companies including Hewlett-Packard and Xerox that stand to financially benefit from such an electronic system. And, as the RAND policy analysts readily admit in their report, there was no compelling evidence at the time to support their theoretical claims. Moreover, in the four years since the report, considerable data have been obtained that undermine their claims. The RAND study and the Obama proposal it spawned appear to be an elegant exercise in wishful thinking.”

While there are real benefits of EMRs – such as medication alerts, reminders and increased legibility – it turns out that, despite all the hype, there’s no evidence that EMRs actually save the system money and improve outcomes. (They also can’t share data with one another and are cost prohibitive in many cases, but that’s another blog entry.)

Groopman and Hartzband cited several studies demonstrating the problems with EMRs:

“A study of orthopedic surgeons, comparing handheld PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer – 48 compared to seven in the paper-based cohort. … A 2008 study published in Circulation, a premier cardiology journal, assessed the influence of electronic medical records on the quality of care of more than 15,000 patients with heart failure. It concluded that ‘current use of electronic health records results in little improvement in the quality of heart failure care compared with paper-based systems.’ Similarly, researchers from the Brigham and Women’s Hospital and Harvard Medical School, with colleagues from Stanford University, published an analysis in 2007 of some 1.8 billion ambulatory care visits. These experts concluded, ‘As implemented, electronic health records were not associated with better quality ambulatory care.’ And just this past January, a group of Canadian researchers reviewed more than 3,700 published papers on the use of electronic medical records in primary care delivered in seven countries. They found no solid evidence of either benefits or drawbacks accruing to patients. This gap in knowledge, they concluded, ‘should be of concern to adopters, payers, and jurisdictions.’”

The bottom line: Once again, physicians are being told to invest their time and dollars in an unproven strategy on the hope that it will eventually pay off. An alternative approach, one advocated by the Network for Regional Healthcare Improvement, would be to create a system that rewards physicians and pays them fairly for achieving the desired outcomes regardless of the specific technology or tools they employ.

It is a constant source of amazement that self-proclaimed health policy “experts” seem to accept as a matter of faith that replacing hundreds of dollars worth of paper in every medical office with tens of thousands of dollars of EMR hardware and software will cause health care costs to plummet.  Of course, our government appears to think that we can spend our way out of a recession and big business sees nothing amiss about being flown into Washington, D.C. in a private jet to beg for taxpayer money to prop up the corporation they’ve run into the ground.  It all seems to be of a piece with the Alice in Wonderland logic of our time.

Moreover, while EMRs are good at quickly generating large, detailed notes, they are less adept at producing concise, actionable information as noted by Grider, et al in Medical Economics:

In April 2008, a study published in the New England Journal of Medicine reported similar problems, pointing out that “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.”

The study also reported an example of the consequences of these problems: “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 . . . Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.”

It gets even better.  From a medicolegal standpoint, those big, impressive EMR notes may be less of a shield than a lightning rod:

[C]ertain types of data-entry functionality…result in “cloned documentation,” in which the records of every visit read almost word-for-word the same except for minor variations confined almost exclusively to the chief complaint.

Physicians have long been counseled that a well-documented medical record provides the best defense in the event of a claim of medical liability. The June 2008 issue of the Journal of AHIMA quoted EHR legal expert Patricia Trites on the potential danger of electronic systems that permit copying of near-identical documentation into large numbers of patient records: “From a medical-legal standpoint, what would [lawyers] do when they [see] this chart?” she asks. “They are going to rip it apart.”

Of course, physicians can already do a lot of dubious documentation with check box sheets, or by having a template for their transcriptionist (e.g. “Physical exam: insert normal gynecologic exam into note.”).  And much of the documentation from patient encounter to patient encounter is repetitive:  Most heart exams reveal regular rate and rhythm, normal S1 and S2, no murmurs, gallops, or rubs, for example.  But third party payors have a built-in incentive to try to avoid paying for claims and lawyers will often twist the facts to favor what they are trying to prove:  An overly brief encounter note or a massive, templated encounter note can both be used to argue that the physician is trying to hide something.

I suspect the EMR backlash will continue and grow.

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5 Responses to “EMR panacea under attack”

  1. Boy, I want to hug you, kiss you and worship the ground on which you walk. You are so right, I think I have fallen in love again just reading your posts. I don’t care if you’re a guy or gal, you make so much sense that you can’t help but be a saint for having the balls (or ovaries) to post this message.

    I have been using one of the shitty CCHIT approved monstrosities, eClinicalworks (or “eClinical doesn’t work” as we call it in our office) for over 2 years. Despite investing hundreds of hours just to customize the damn POS, I can say I am only perhaps marginally better off. The only reason being I code LOTS of high level visits. But, patient care is the same; for everything the software improves, it makes something else more error prone. It’s always crashing. The interface requires you get into 3-4 (slowly) loading screens, and then back track for every single tiny little thing you do, and clicking all over the place is the word of the day. What is scary is that eClinicalworks is supposed to be one of the better ones. Hell, its interface feels like it’s from 1993, WTF?! In any other field, such poor quality and obsolete interface/mechanics would be ridiculed. Only doctors are gullible and naive and trusting to buy these.

    I am very saddened to see government, payors, and the charlatans who sell this snake oil. What is shocking is that until last year, the net was nothing but deluged about how great and wonderful these systems are, and how their CEO’s hold babies, kiss little girls, and have baby jesus himself bless their sacred systems. Fuck that shit, they are selling snake oil, pure and simple. I have used enough systems (about a total of 7) through my travels to know they all are difficult to use, hard to implement, provide marginal, if any benefit at all but require herculean travails just to get them to work.

    One note of hope: only 17% of doctors use any type of “approved” EMR, and less than a quarter (only about 4% of all docs) use it to capacity. I wonder why. As naive and gullible as docs are, we aren’t totally stupid, and we’re catching on. Show me a good EMR that can talk to all the others, including the pharmacy, and automatically updates itself to include every event that ever happens to a patient from womb to tomb, I’d love it. Have that EMR have sentence finishing capability, I’d be in love. It’s already here: word processing with intelligence. Word is starting to, and there is translation software out there which pretty much tries to anticipate what you type and gives you an active, dynamic “pick list” based on what you are typing that finishes sentences and helps you finish typing something in 25% the time it normally would.

    What we have now are systems that were born in the 1990s and are long past their prime, only gussied up to have features that their vendors are made to have in word only. Drug interaction databases or allergy warnings? Please those are a joke too, so clunky that it tells you compazine is “RED ALERT” on an asthma patient because “IT WILL MAKE THEM STOP BREATHING”.

    The kool aid wore off. I have awoken to a very bad hangover, and an even worse marriage to an EMR, one that I sadly cannot leave. I am happy to see backlash against EMR’s. The public needs to know how much they suck. If my scathing post can save just ONE person from going through the living hell that eClinicalworks put me through, or for that matter, any of these junk systems can, it will have been worth posting. I wouldn’t wish what eClinicalworks put us through on my worst enemy, and it seems like all its competition is just as lousy.

  2. Zach Mellman Says:

    I am curious whether you believe a good standalone e-prescribing system can serve as a stepping stone for EMR adpotion, if/when they do become “ready for prime time?”

    • I’d be inclined to say yes, although at my own office true e-prescribing is being held up as a result of the merger of two of the major e-prescribing companies. No one knows, or so my EMR vendor tells me, what format or protocol for e-prescribing will prevail, so the writers of code are waiting lest they prepare their EMR for “A” only to discover that “B” or perhaps a “C” format that doesn’t yet exist has won out.

      • Zach Mellman Says:

        My apologies, I forgot my comment back in July.

        I’m surprised that two of the major e-prescribing companies have merged, I am very interested to know who they are, would you mind sharing this with me?

  3. “ecwdissapointed” is my new hero! Over the last few years, I have come in contact with many colleagues in private practice, all that have had very similar experiences with eClinical and feel the same way (rough language and all). I count myself among them. The more time passes, the more I count my purchase of eClinical as one of the worst decisions I have ever made. There product has put me in a terrible possition, because I am now in so deep, I don’t think I can ever recover. I have heard that other emr systems have their own downsides, but nothing compared to eClinical. If it’s true that most emr’s are lacking, then our country is in for a rude awakening when we realize that putting all our eggs in the emr basket left us with a mess! I know that I often feel helpless, and as though speaking up will open me up to harsh criticism from those who are willing to deal with such an inferrior product. Or worse yet liability, if others only knew how vulnerable eClinical has made me. I think if more physicians spoke up, we would all be surprised by our numbers. I say, safety in numbers! Doctors unite and speak out about eClinical. You are not alone.

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