9 ms·

Some doctors think EHRs are hurting their relationships with patients

68 points by rexercises 9y ago

Powerofmene 9y ago
I agree with this. Over the past five to six years I have taken my aging parents to many physician appointments. In the past two years I have seen time spent with physicians expand from five to seven minutes to thirty to thirty five minutes. Less physical exams and more typing, typing and typing. As a result when you need an appointment what you hear is that nothing is available for three to five days. Numerous times I was unable to get my Dad in for over a week when he needed to be seen. Sometimes progress is not progress for everyone.
- binarymax 9y ago
  Anecdotal and varies by physician and care center. My folks can get booked and seen quickly and efficiently. I should add that while the extra data capture may now seem like an issue, when federated access is better supported it will be a boon to healthcare. Aside, since when does PBS write such clickbait? The article clearly gives advantages and drawbacks with the current system compared to old. Why not give a professional quality title?
  - Powerofmene 9y ago
    Yes it is anecdotal but I was giving my perspective based on the last couple of years of taking my parents to their physician appointments. Given that we have long-standing relationships with our doctors they have shared their displeasure with the new systems and how it is resulting in longer wait times to get appointments. We have repeatedly experienced this. I know many individuals who are not and find that doctors offices who are not accepting new Medicare patients are experiencing this less than those that are still accepting new patients. It is likely that these issues are also geographical in nature as some areas are not experiencing the physician shortages or patient loads that other areas and physicians are experiencing.
- jimktrains2 9y ago
  "Better never means better for everyone." On a serious note, though, two things I think about when I'm at the doctor and they're just typing in what we're talking about: * It's an evolving tech; it'll slowly change * How happy the doctor and patient are with the system isn't measured, and therefore "doesn't matter".
kazinator 9y ago
If your doc is typing away and looking at the screen, it shows lack of preparation. He or she should have reviewed those records ahead of the appointment. Nothing wrong with those records being electronic.
- wyldfire 9y ago
  Not trying to excuse the bad behavior of the Physician disengaging from patient care, but often what's taking place is the Physician recording elements of the patient's history currently being relayed by the patient themselves and the examination in progress. This can't be done in advance of the exam (although they could be done after). The fact that it's electronic enables administrators (emboldened by EMR/EHR vendors) to claim that "it's convenient" enough to be done in the room (faster than writing it down by hand or transcribed via recording after the exam ends).
- ch4s3 9y ago
  >Nothing wrong with those records being electronic. Agreed. But, you doctor likely is scheduled such that they have less than 45 minutes per patient including reviewing records. Additionally, the relevant records may have been gather during intake by a nurse or MA, so they aren't available in advance. Better EHR UX could probably alleviate this problem.
- rscho 9y ago
  You have no idea of what you are talking about. Of course the doc also has to input the data he is gathering on the spot while talking to you. Plus, preparing files beforehand means sequential execution. Hospitals don't like that. They want parallel execution. As in doing it all at once, at the expense of patient comfort, with the aim of cramming as much work as possible in the minimum time.
- pg_bot 9y ago
  I don't think you understand the amount of information overload that comes with medical records. A typical medical record can contain more than 100 pages of documentation. I've seen records that span more than 1500 pages. While most medical records are electronic, systems do not interoperate with one another. So, you are forced to type in relevant information from a fax into your EHR system. Most of the pain comes with documentation necessary for dealing with billing and insurance. In fact most of the language is super vague so that you can cover your ass if someone tries to sue you. Disclosure: I run a start up that is working on solving a lot of these problems.
ortusdux 9y ago
The only times I've seen EHR's work well is when a 2nd person is at the computer typing and the doctor sits with the patient.
- xoail 9y ago
  Yes this is a good option but an expensive one.
davycro 9y ago
Emergency doctor and hacker here. The closed systems and lack of support for interoperability between EHRs upsets me the most because it leads to patient harm. I just had a patient transferred from an outside hospital for abdominal pain and somehow their CT scan was lost in transit. Because it was an emergency we had to CT scan them again which doubled their radiation exposure and their risk for a kidney injury from the iv contrast. It was midnight so it would have taken until business hours to obtain the scans from the hospital. Things like this happen almost daily.
- lbhnact 9y ago
  Just-graduated MD/MPH and former EMT and ED admin here. I empathize strongly, since the first time I watched a 16-year girl who'd been in a MVC and first transported to Duke, who needed sub-specialty consults at UNC get re-scanned. I'd read about CT dosing and realized that we had just increased this girls lifetime likelihood of ovarian or endometrial cancer by perhaps about 1/1000. For absolutely no reason other than the fact we couldn't get the images 8 miles down the road from the Duke ED, and the attending wanted to 'just be sure'. I asked the resident why they couldn't send them digitally and they just laughed. That was 2009. It's 8 years and a few hundred billion of national EMR spend later - and you know what? We still can't send an image between the two EDs. UNC and Duke were the first two nodes/servers on Usenet back in 1980[1], and 37 years later we can barely exchange medical data using our combined 1.3 billion dollars of Epic EMR implementations. This problem harms people needlessly every day. Please use your voice as a provider to remind people whenever possible. [1]https://en.wikipedia.org/wiki/Usenet https://en.wikipedia.org/wiki/Usenet
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- mindcrime 9y ago
  The closed systems and lack of support for interoperability between EHRs upsets me the most because it leads to patient harm. As a patient here's what gets me: UNC has one EMR system, my GP has another, and Duke has yet another. I've been a patient at all 3 at various times. I also use Strava, Fitbit, and the like. Now you would think that it would be trivially easy to use an API and export and aggregate all of my lab results, for things like blood pressure, cholesterol, etc., so I can graph, say, my blood pressure and my Strava activity together. But nooooo... all of these EMR systems either have no export functionality / API, or if they do, it's something byzantine and just-short-of-impossible-to-use. Of course not every patient is a data geek who's going to use machine learning, statistical analysis and visualizations on their own data. But for those of us who want to, the roadblocks to doing so are infuriating. I just had a patient transferred from an outside hospital for abdominal pain and somehow their CT scan was lost in transit. Because it was an emergency we had to CT scan them again which doubled their radiation exposure and their risk for a kidney injury from the iv contrast. It was midnight so it would have taken until business hours to obtain the scans from the hospital. The doubly sad part is that this is almost 100% a policy / business issue and not a technical one. We've known how to share data for a long time. Heck, IIRC, a scenario much like the one listed above was used as an illustrative example for justifying the WS-Federation[1] protocol way back when. Edit: Yep, this document[2] explaining WS-Federation actually uses an emergency room scenario to justify the need for WS-Federation. Not the exact same scenario as above, but the point stands. We've had protocols and technologies for doing this stuff for a long time. [1]: https://en.wikipedia.org/wiki/WS-Federation https://en.wikipedia.org/wiki/WS-Federation [2]: http://download.boulder.ibm.com/ibmdl/pub/software/dw/specs/ws-fed/WS-FederationSpec05282007.pdf?S_TACT=105AGX04&S_CMP=LP http://download.boulder.ibm.com/ibmdl/pub/software/dw/specs/...
portmanteaufu 9y ago
EHR = Electronic Health Records
Insanity 9y ago
I work on an EHR. I work in a hospital on an EHR that is used in a network of about 20 hospitals. A frequent complaint I tend to hear is that the doctors just want to be busy with their patient and not with the software. We try to make the software as easy to use as possible, but it is still slower than them just working on paper for many things (like sharing notes quickly between them and their assistants). On the other hand, I do think that an EHR can be a good thing. Because we work closely with the doctors we can tweak things to their liking. Some departments spent a great deal more time on tweaking the software (mostly younger doctors) and that pays off for them. They lose less time with the software and the software becomes an aid for them - as it should be. It does not happen in every department of all of the 20 something hospitals, but it _can_ be good. From what I have seen in this industry - the worst thing you can do as a hospital is buy an EHR package by a company that is not working closely with others in the medical field. You need communication between the departments and the engineers, and a short release-cycle surely helps.
- apathy 9y ago
  Serious question: does your company have a clause in the service contract that forbids disclosing, documenting, or photographing potentially catastrophic bugs in the software? Aka do you work for Epic
- loa_in_ 9y ago
  What I learnt from the software I use most is that best productivity software has at least some of traits: - is complex, but has a fast route for most common things (e.g. placeholder text for all fields where such text can be applicable; lots of checkboxes but also a button that selects a set of most common ones while unselecting most uncommon ones; etc.) - has features that enable automation and customisation (macros, user defined presets, sharing of those presets in something not unlike Steam Workshop, key shortcuts for EVERYTHING but unbound by default) - has user profiles (most linux tools are simply tied to your home directory, so it's a feature of the system, I can imagine though that doctors share their offices and computers, so it's something that needs to be included as a feature of the software itself)
- specialist 9y ago
apathy 9y ago
More interesting would be if anyone can find a physician who actually "appreciates" EHRs. I watched a few with 50+ years in practice decide to retire upon Epic rollout. EHRs are a farce. They've made a few people very wealthy at the cost of widespread misery for patients and doctors.
- shishy 9y ago
  Sorry, I'm a little confused by your comment. You saw a few physicians with 50+ years in practice retire upon the Epic rollout? Maybe they were of old age and near retirement? And also, how does that lead to your conclusion that they are a "farce"? Do you mean to suggest that we would be better off without EHRs, or do you specifically have issue with the implementation of EHRs as is right now? I'm surprised by you calling them a "farce" and causing "widespread misery for patients and doctors" because my understanding was that the clinical data collected by EHRs permitted improvements in the quality and delivery of care for patients within an institution. I will admit that - as mentioned elsewhere in these comments - lack of interoperability is a huge issue which drastically reduces the effectiveness of EHRs. But even though it isn't a perfect system -- 1) It is an improvement over the previous form of paper records, and 2) The industry is iteratively moving to resolve these issues. There are a lot of reasons for why these problems exist such as misaligned incentives, etc. but we have been trying to address this through both policy (e.g. the rise of accountable care organizations and how the ACA experimented with physician reimbursements). There also exist middleware solutions that I believe would help ensure that this data is not silo'd, and in doing so improve interoperability. Maybe I'm just misunderstanding something but if I am, could someone please point it out? I'm not saying that EHRs are perfect -- they have a way to go (both in UX design/interoperability). But, they were a step in the right direction and I am not convinced that they are as bad as you claim they are (though I recognize their limitations). What am I missing? EDIT: I've also heard from physicians and patients that because EHRs easily allow a doctor to read up on a patient's notes from their previous visits, it can actually improve their relationship because the doctor can go into the room for subsequent visits knowing something (or in some cases, everything) about the patient and speak to them with that information in mind.
  - 9y ago
athenot 9y ago
> "He says EHRs now function primarily as documentation for billing and quality reporting rather than as an aid to doctors." This is the money quote right there. EHRs are purchased by hospital administrators, the people who are worried about cost and compliance. They are the ones who get to dictate the features to the EHR vendor in the selection process. Yes clinical staff is consulted but usability is only ever a consideration when a high-enough ranking doctor goes on a rant about it.
- CaptSpify 9y ago
  This is a big problem with these "top-down" systems in general. Look at educational systems and you'll see the same problem. Teachers generally hate their electronic record-keeping tools, but they generally have no voice in which tool is chosen. It's all up to someone up top (who has no idea how day-to-day operations work) that makes the call. The same thing happens in finance, warehouse work, etc etc.
  - greenshackle2 9y ago
    I code ERPs, it's a big problem there. I push to talk to the end users directly but it's not rare that the project owner on both our side and the client side wants everything to go through them. Instead of: Coder: Hey, end-user, does this data model / interface makes sense for your work? End-user: Nah, something more like ... would make more sense. It's: Coder: I'm not sure which of designs A, B, or C would make more sense for detail X of feature Y (see ambiguous specification, section 2.2.2.3.a.alpha). Project owner: Ok I'll check with the client. writes email Client's project owner: Hmm I'll ask my people. 2 days later Project owner: I've updated the specs. Coder: checks specs That... doesn't answer the question.
- flldikeud39 9y ago
  I'm a healthcare provider and have worked in a various EHR settings. I have mixed feelings about all of this, and think the problem with EHRs isn't really the EHRs, it's the systemic problems underlying the EHRs. The EHRs are just a tangible way to vent about them. First, the way these EHRs were rolled out, under federal mandate, was a fucking fiasco. I am definitely not anti-government when it comes to healthcare, but I do not think EHRs should have been mandated. People forget that in all of this. Administrators did not want to purchase them, because they were huge cost sinks (the rollout of one EHR at a hospital my wife works at was 2 billion dollars over what they initially estimated it to be). So, you have these systems which weren't purchased because they were appealing solutions, or cost effective, but because the hospitals had to to avoid losing reimbursements. This led to systems being rushed early, without adequate hardening, and all sorts of things. Before EHRs, records were done in-house by people who were highly trained in this area. My guess is that if markets had been allowed to progress naturally, you would have seen more in-house open-source implementations that would have happened more gradually, at much lower cost, and with more back-and-forth with providers. Second, I'm a little tired of griping from physicians about having to do paperwork. Sorry if this comes across as hostile, but a lot of it is narcissistic bullshit, frankly. Records in high-stakes settings is not just about documentation, it's about checks, and making sure you're following protocol. Studies have shown this increases safety. We all have to do it. Someone asked about scribes, but wait until some lawsuit happens because of ambiguity about whose responsibility it was when some instruction or note was done incorrectly. This way, it's ultimately the provider's responsibility, coming directly from them. And yes, you can still do transcription for lengthy notes. I know this because I've done it. One of the elephants in the room when it comes to healthcare costs is that there's too much top-down authority, too much monopoly, too little competition in provider models, and people feed into this when they start going down the route of suggesting it's too much to ask physicians to be responsible for their own damn communication with the rest of the providers in healthcare. Finally, going back to my original point: the real problem in a lot of cases isn't the EHRs, it's the business-model administrative hierarchy that's taking over all sorts of fields. Regardless of whether or not this should be the case, physicians want to be in charge, to have autonomy and authority, and suddenly they're finding themselves being treated like widgets in a vast healthcare machine that benefits administration primarily. They have to use some system they didn't approve of, and they realize that the decisions in some sense aren't coming from them, they're being told what to do by administration. So rather than feeling like they're the top dog at the hospital, they're feeling like cubicle workers. That's what I suspect this is mostly about, not the time with patients, or whatever the hell the complaint du jour is. Note that on this point I sympathize with them--this administrative hierarchical model that's squeezing workers, whether it be healthcare, or IT, or education, or whatever, is fundamentally flawed. It's just new to physicians, or something they didn't think they'd have to deal with. This is my little tangential rant, but I'm sick of healthcare discussions in congress being so focused on costs, and not on deregulating healthcare and increasing transparency. There needs to be less of this kind of EHR red tape, more use of EHRs that is driven by their utility, more competition among provider models, greater consumer access to drugs and healthcare options (and I don't mean by giving them more money, I mean by letting them do whatever the hell they want), and more transparency about costs. Right now, we have a model where you have an extremely small number of people telling everyone else--including different types of providers, as well as consumers--what they can and cannot do with their own healthcare decisions, and billing them without them even knowing or agreeing to the cost of a service. Imagine if the government said that only accountants they approve of, with doctoral level finance degrees, could do your taxes, and that those accountants could charge whatever they want without telling you the cost ahead of time. People would be in an uproar. We spend all this time assuming that our healthcare system should basically stay as it is, but that we should reorganize how we pay for things, when the discussion should be about both.
twobyfour 9y ago
Were global (or at least nationwide) technical standards and specifications for data exchange protocols never defined as part of this mandate?
- lbhnact 9y ago
  No they were not. The quote, by David Blumenthal who designed the HITECH legistlation said this: "Before you can create interoperability, you have to create operability"[1] I'll leave it to you to decide whether this was a wise philosophy to underpin a major national IT project. [1]http://www.healthcareitnews.com/news/blumenthal-look-stage-1-meaningful-use-upshot-next-winter http://www.healthcareitnews.com/news/blumenthal-look-stage-1...
  - dragonwriter 9y ago
    It seems to be the exact opposite philosophy that HIPAA originally took in the effort to get financial/administrative transactions to electronic formats, which was essentially that mandating interoperability would drive mainstream use.
- nwhatt 9y ago
  Nationwide yes - The program is commonly referred to as Meaningful Use. There were a number of requirements related to data exchange, and it moved the needle slightly. All the requirements are written as a numerator/denominator format. For example, 25% of all lab orders placed by a provider need to be resulted electronically. So there's an incentive to integrate some things, but not all. Edit: here are the 2015 rules and accompanying underlying standards: https://www.healthit.gov/policy-researchers-implementers/2015-edition-test-method https://www.healthit.gov/policy-researchers-implementers/201...
  - lbhnact 9y ago
    Without bickering over MU requirements, you'd probably note that MU has been almost entirely ineffective at solving actual care problems with data exchange. Of 50 state exchanges, most have collapsed, with only occasional use of the ad-hoc implementations and networks that remain. And people dying everyday while vendors like ECW get wrist-slaps for lying to CMS about their MU compliance. -http://www.healthcareitnews.com/news/eclinicalworks-pay-155-million-settle-suit-alleging-it-faked-meaningful-use-certification http://www.healthcareitnews.com/news/eclinicalworks-pay-155-...
koolba 9y ago
For situations like this I wonder if it'd be easier/cheaper to hire a scribe to shadow the doctor. Compared to the doctor's salary, the cost of the scribe would be a rounding error. The doctor could scribble illegible notes or maybe take no notes at all, and the scribe could type up the details (either on the spot or after the fact).
- markolschesky 9y ago
  That's actually pretty common, especially for older physicians or high-volume specialists. There are also some companies working on solutions to automate this using in-room speech recognition technologies like https://iscribes.co/ https://iscribes.co/.
throwthisawayt 9y ago
My partner is a doctor who works at one the top medical systems in America. The EHR system she works is atrocious. Last time she asked me to look at it to help figure out how to print an image and I stared at this 90s era windows app that looked like the pied piper interface. I gave up after 15 minutes and we ended up screenshoting the image. Taleo felt like it had a better UX than it. I can't believe we let some of best doctors in the country waste hours each day fighting with terrible software instead of treating patients. My partner spends more time trying to figure out the EHR than she does treating patients.
xoail 9y ago
I am seeing this issue 2nd hand and I totally get it. My aunt runs a practice and her time with the patients dropped significantly. She is also unable to see as many patients as she used to before the mandate. While I've built few nifty tools (chrome extensions and macros) for her to simplify some of the cumbersome tasks, I am envisioning and planning to build a whole new EHR solution from scratch that puts doctors first, as my side project. It's a daunting task and requires expert domain knowledge. Hoping to get an MVP by end of year.
- CabSauce 9y ago
  Please build it around a standard (FHIR).
  - xoail 9y ago
    Yes, this is so important and yet I see many EHR companies relax on it since its not heavily mandated.
hyperion2010 9y ago
Last time I went to see the optometrist (who keeps and all paper office) he told that he has started to see a huge uptick in fraud. How did he know? He started seeing records from certain docs where they did the full workup on every single patient. There is no way they could do this, a full workup takes between 5 and 7 hours (he said). So what was happening? Someone at these offices had filled out the 'full workup' form for their EHRs and then discovered that they now literally had a button that would print money (paid out by insurance companies). If you give someone a tool that lets them print money at the click of a button even if it means they didn't actually do all the tests to fill it in they are going to click it.
- Johnny555 9y ago
  Do you need EHR's to do this? Spending 30 minutes filling out paperwork documenting a fake 7 hours of work sounds like it's still profitable.
  - hyperion2010 9y ago
    Most offices don't have someone with 30 minutes of their day to spare (per patient!), so if they are doing this they basically need someone dedicated to the fraud. Now it is 30 minute time cost up front and then they just select it from the dropdown box.
Skeletor 9y ago
This is the kind of thing that we are trying to fix at drchrono. I think legacy EMR interfaces that are heavily reliant on keyboard/mouse interfaces are too distracting. Mobility (iPad's for drchrono) are just starting to make a bigger impact on the market and I think over the next 5 years 80% of providers in the US will be using a mobile interface (probably an iPad) and not touching a keyboard/mouse while a patient is in the room.
- walshemj 9y ago
  how do you get round the sterility cleaning requirements I the UK all the pc's I see the doctors and ward staff using have special wipe clean keyboards etc>
  - Skeletor 9y ago
    http://www.wikihow.com/Clean-Your-iPad http://www.wikihow.com/Clean-Your-iPad https://discussions.apple.com/thread/4383886?start=0&tstart=0 https://discussions.apple.com/thread/4383886?start=0&tstart=... I clean my personal iPhone/iPad once every few months. I think it's much easier and more possible to sterilize a glass/metal ipad than a keyboard (especially for onboarding of patients in a waiting room.)
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Johnny555 9y ago
AS a patient, I like Kaiser's EHR system -- the doctor talks to me, then pauses as he documents on the computer from time to time - he doesn't type while we talk. That doesn't seem noticeably worse than him staring at his clipboard while I'm talking with him. But the part I really like is that I have access to most test results online. And since Kaiser is a self-contained HMO and doesn't generally do referrals outside of their system, interoperability isn't really an issue -- when I get referred to a Kaiser specialist or move to a new area and start seeing a new doctor, I know they'll have access to my records. In a previous system, I had to see a specialist, and though they requested that my original doctor transfer all records, not all of the records were sent and I ended up having to reschedule an appointment so I could pick up the missing records and take with with me.

68 points by rexercises 9y ago

I agree with this. Over the past five to six years I have taken my aging parents to many physician appointments. In the past two years I have seen time spent with physicians expand from five to seven minutes to thirty to thirty five minutes. Less physical exams and more typing, typing and typing. As a result when you need an appointment what you hear is that nothing is available for three to five days. Numerous times I was unable to get my Dad in for over a week when he needed to be seen. Sometimes progress is not progress for everyone.

binarymax 9y ago
Anecdotal and varies by physician and care center. My folks can get booked and seen quickly and efficiently. I should add that while the extra data capture may now seem like an issue, when federated access is better supported it will be a boon to healthcare. Aside, since when does PBS write such clickbait? The article clearly gives advantages and drawbacks with the current system compared to old. Why not give a professional quality title?
- Powerofmene 9y ago
  Yes it is anecdotal but I was giving my perspective based on the last couple of years of taking my parents to their physician appointments. Given that we have long-standing relationships with our doctors they have shared their displeasure with the new systems and how it is resulting in longer wait times to get appointments. We have repeatedly experienced this. I know many individuals who are not and find that doctors offices who are not accepting new Medicare patients are experiencing this less than those that are still accepting new patients. It is likely that these issues are also geographical in nature as some areas are not experiencing the physician shortages or patient loads that other areas and physicians are experiencing.
jimktrains2 9y ago
"Better never means better for everyone." On a serious note, though, two things I think about when I'm at the doctor and they're just typing in what we're talking about: * It's an evolving tech; it'll slowly change * How happy the doctor and patient are with the system isn't measured, and therefore "doesn't matter".

kazinator 9y ago

If your doc is typing away and looking at the screen, it shows lack of preparation. He or she should have reviewed those records ahead of the appointment. Nothing wrong with those records being electronic.

wyldfire 9y ago
Not trying to excuse the bad behavior of the Physician disengaging from patient care, but often what's taking place is the Physician recording elements of the patient's history currently being relayed by the patient themselves and the examination in progress. This can't be done in advance of the exam (although they could be done after). The fact that it's electronic enables administrators (emboldened by EMR/EHR vendors) to claim that "it's convenient" enough to be done in the room (faster than writing it down by hand or transcribed via recording after the exam ends).
ch4s3 9y ago
>Nothing wrong with those records being electronic. Agreed. But, you doctor likely is scheduled such that they have less than 45 minutes per patient including reviewing records. Additionally, the relevant records may have been gather during intake by a nurse or MA, so they aren't available in advance. Better EHR UX could probably alleviate this problem.
rscho 9y ago
You have no idea of what you are talking about. Of course the doc also has to input the data he is gathering on the spot while talking to you. Plus, preparing files beforehand means sequential execution. Hospitals don't like that. They want parallel execution. As in doing it all at once, at the expense of patient comfort, with the aim of cramming as much work as possible in the minimum time.
pg_bot 9y ago
I don't think you understand the amount of information overload that comes with medical records. A typical medical record can contain more than 100 pages of documentation. I've seen records that span more than 1500 pages. While most medical records are electronic, systems do not interoperate with one another. So, you are forced to type in relevant information from a fax into your EHR system. Most of the pain comes with documentation necessary for dealing with billing and insurance. In fact most of the language is super vague so that you can cover your ass if someone tries to sue you. Disclosure: I run a start up that is working on solving a lot of these problems.

ortusdux 9y ago

The only times I've seen EHR's work well is when a 2nd person is at the computer typing and the doctor sits with the patient.

xoail 9y ago
Yes this is a good option but an expensive one.

davycro 9y ago

Emergency doctor and hacker here. The closed systems and lack of support for interoperability between EHRs upsets me the most because it leads to patient harm. I just had a patient transferred from an outside hospital for abdominal pain and somehow their CT scan was lost in transit. Because it was an emergency we had to CT scan them again which doubled their radiation exposure and their risk for a kidney injury from the iv contrast. It was midnight so it would have taken until business hours to obtain the scans from the hospital. Things like this happen almost daily.

lbhnact 9y ago
Just-graduated MD/MPH and former EMT and ED admin here. I empathize strongly, since the first time I watched a 16-year girl who'd been in a MVC and first transported to Duke, who needed sub-specialty consults at UNC get re-scanned. I'd read about CT dosing and realized that we had just increased this girls lifetime likelihood of ovarian or endometrial cancer by perhaps about 1/1000. For absolutely no reason other than the fact we couldn't get the images 8 miles down the road from the Duke ED, and the attending wanted to 'just be sure'. I asked the resident why they couldn't send them digitally and they just laughed. That was 2009. It's 8 years and a few hundred billion of national EMR spend later - and you know what? We still can't send an image between the two EDs. UNC and Duke were the first two nodes/servers on Usenet back in 1980[1], and 37 years later we can barely exchange medical data using our combined 1.3 billion dollars of Epic EMR implementations. This problem harms people needlessly every day. Please use your voice as a provider to remind people whenever possible. [1]https://en.wikipedia.org/wiki/Usenet https://en.wikipedia.org/wiki/Usenet
- deleted 9y ago
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mindcrime 9y ago
The closed systems and lack of support for interoperability between EHRs upsets me the most because it leads to patient harm. As a patient here's what gets me: UNC has one EMR system, my GP has another, and Duke has yet another. I've been a patient at all 3 at various times. I also use Strava, Fitbit, and the like. Now you would think that it would be trivially easy to use an API and export and aggregate all of my lab results, for things like blood pressure, cholesterol, etc., so I can graph, say, my blood pressure and my Strava activity together. But nooooo... all of these EMR systems either have no export functionality / API, or if they do, it's something byzantine and just-short-of-impossible-to-use. Of course not every patient is a data geek who's going to use machine learning, statistical analysis and visualizations on their own data. But for those of us who want to, the roadblocks to doing so are infuriating. I just had a patient transferred from an outside hospital for abdominal pain and somehow their CT scan was lost in transit. Because it was an emergency we had to CT scan them again which doubled their radiation exposure and their risk for a kidney injury from the iv contrast. It was midnight so it would have taken until business hours to obtain the scans from the hospital. The doubly sad part is that this is almost 100% a policy / business issue and not a technical one. We've known how to share data for a long time. Heck, IIRC, a scenario much like the one listed above was used as an illustrative example for justifying the WS-Federation[1] protocol way back when. Edit: Yep, this document[2] explaining WS-Federation actually uses an emergency room scenario to justify the need for WS-Federation. Not the exact same scenario as above, but the point stands. We've had protocols and technologies for doing this stuff for a long time. [1]: https://en.wikipedia.org/wiki/WS-Federation https://en.wikipedia.org/wiki/WS-Federation [2]: http://download.boulder.ibm.com/ibmdl/pub/software/dw/specs/ws-fed/WS-FederationSpec05282007.pdf?S_TACT=105AGX04&S_CMP=LP http://download.boulder.ibm.com/ibmdl/pub/software/dw/specs/...

portmanteaufu 9y ago

EHR = Electronic Health Records

Insanity 9y ago

I work on an EHR. I work in a hospital on an EHR that is used in a network of about 20 hospitals. A frequent complaint I tend to hear is that the doctors just want to be busy with their patient and not with the software. We try to make the software as easy to use as possible, but it is still slower than them just working on paper for many things (like sharing notes quickly between them and their assistants). On the other hand, I do think that an EHR can be a good thing. Because we work closely with the doctors we can tweak things to their liking. Some departments spent a great deal more time on tweaking the software (mostly younger doctors) and that pays off for them. They lose less time with the software and the software becomes an aid for them - as it should be. It does not happen in every department of all of the 20 something hospitals, but it _can_ be good. From what I have seen in this industry - the worst thing you can do as a hospital is buy an EHR package by a company that is not working closely with others in the medical field. You need communication between the departments and the engineers, and a short release-cycle surely helps.

apathy 9y ago
Serious question: does your company have a clause in the service contract that forbids disclosing, documenting, or photographing potentially catastrophic bugs in the software? Aka do you work for Epic
loa_in_ 9y ago
What I learnt from the software I use most is that best productivity software has at least some of traits: - is complex, but has a fast route for most common things (e.g. placeholder text for all fields where such text can be applicable; lots of checkboxes but also a button that selects a set of most common ones while unselecting most uncommon ones; etc.) - has features that enable automation and customisation (macros, user defined presets, sharing of those presets in something not unlike Steam Workshop, key shortcuts for EVERYTHING but unbound by default) - has user profiles (most linux tools are simply tied to your home directory, so it's a feature of the system, I can imagine though that doctors share their offices and computers, so it's something that needs to be included as a feature of the software itself)
specialist 9y ago

apathy 9y ago

More interesting would be if anyone can find a physician who actually "appreciates" EHRs. I watched a few with 50+ years in practice decide to retire upon Epic rollout. EHRs are a farce. They've made a few people very wealthy at the cost of widespread misery for patients and doctors.

shishy 9y ago
Sorry, I'm a little confused by your comment. You saw a few physicians with 50+ years in practice retire upon the Epic rollout? Maybe they were of old age and near retirement? And also, how does that lead to your conclusion that they are a "farce"? Do you mean to suggest that we would be better off without EHRs, or do you specifically have issue with the implementation of EHRs as is right now? I'm surprised by you calling them a "farce" and causing "widespread misery for patients and doctors" because my understanding was that the clinical data collected by EHRs permitted improvements in the quality and delivery of care for patients within an institution. I will admit that - as mentioned elsewhere in these comments - lack of interoperability is a huge issue which drastically reduces the effectiveness of EHRs. But even though it isn't a perfect system -- 1) It is an improvement over the previous form of paper records, and 2) The industry is iteratively moving to resolve these issues. There are a lot of reasons for why these problems exist such as misaligned incentives, etc. but we have been trying to address this through both policy (e.g. the rise of accountable care organizations and how the ACA experimented with physician reimbursements). There also exist middleware solutions that I believe would help ensure that this data is not silo'd, and in doing so improve interoperability. Maybe I'm just misunderstanding something but if I am, could someone please point it out? I'm not saying that EHRs are perfect -- they have a way to go (both in UX design/interoperability). But, they were a step in the right direction and I am not convinced that they are as bad as you claim they are (though I recognize their limitations). What am I missing? EDIT: I've also heard from physicians and patients that because EHRs easily allow a doctor to read up on a patient's notes from their previous visits, it can actually improve their relationship because the doctor can go into the room for subsequent visits knowing something (or in some cases, everything) about the patient and speak to them with that information in mind.
- 9y ago

athenot 9y ago

> "He says EHRs now function primarily as documentation for billing and quality reporting rather than as an aid to doctors." This is the money quote right there. EHRs are purchased by hospital administrators, the people who are worried about cost and compliance. They are the ones who get to dictate the features to the EHR vendor in the selection process. Yes clinical staff is consulted but usability is only ever a consideration when a high-enough ranking doctor goes on a rant about it.

CaptSpify 9y ago
This is a big problem with these "top-down" systems in general. Look at educational systems and you'll see the same problem. Teachers generally hate their electronic record-keeping tools, but they generally have no voice in which tool is chosen. It's all up to someone up top (who has no idea how day-to-day operations work) that makes the call. The same thing happens in finance, warehouse work, etc etc.
- greenshackle2 9y ago
  I code ERPs, it's a big problem there. I push to talk to the end users directly but it's not rare that the project owner on both our side and the client side wants everything to go through them. Instead of: Coder: Hey, end-user, does this data model / interface makes sense for your work? End-user: Nah, something more like ... would make more sense. It's: Coder: I'm not sure which of designs A, B, or C would make more sense for detail X of feature Y (see ambiguous specification, section 2.2.2.3.a.alpha). Project owner: Ok I'll check with the client. writes email Client's project owner: Hmm I'll ask my people. 2 days later Project owner: I've updated the specs. Coder: checks specs That... doesn't answer the question.
flldikeud39 9y ago
I'm a healthcare provider and have worked in a various EHR settings. I have mixed feelings about all of this, and think the problem with EHRs isn't really the EHRs, it's the systemic problems underlying the EHRs. The EHRs are just a tangible way to vent about them. First, the way these EHRs were rolled out, under federal mandate, was a fucking fiasco. I am definitely not anti-government when it comes to healthcare, but I do not think EHRs should have been mandated. People forget that in all of this. Administrators did not want to purchase them, because they were huge cost sinks (the rollout of one EHR at a hospital my wife works at was 2 billion dollars over what they initially estimated it to be). So, you have these systems which weren't purchased because they were appealing solutions, or cost effective, but because the hospitals had to to avoid losing reimbursements. This led to systems being rushed early, without adequate hardening, and all sorts of things. Before EHRs, records were done in-house by people who were highly trained in this area. My guess is that if markets had been allowed to progress naturally, you would have seen more in-house open-source implementations that would have happened more gradually, at much lower cost, and with more back-and-forth with providers. Second, I'm a little tired of griping from physicians about having to do paperwork. Sorry if this comes across as hostile, but a lot of it is narcissistic bullshit, frankly. Records in high-stakes settings is not just about documentation, it's about checks, and making sure you're following protocol. Studies have shown this increases safety. We all have to do it. Someone asked about scribes, but wait until some lawsuit happens because of ambiguity about whose responsibility it was when some instruction or note was done incorrectly. This way, it's ultimately the provider's responsibility, coming directly from them. And yes, you can still do transcription for lengthy notes. I know this because I've done it. One of the elephants in the room when it comes to healthcare costs is that there's too much top-down authority, too much monopoly, too little competition in provider models, and people feed into this when they start going down the route of suggesting it's too much to ask physicians to be responsible for their own damn communication with the rest of the providers in healthcare. Finally, going back to my original point: the real problem in a lot of cases isn't the EHRs, it's the business-model administrative hierarchy that's taking over all sorts of fields. Regardless of whether or not this should be the case, physicians want to be in charge, to have autonomy and authority, and suddenly they're finding themselves being treated like widgets in a vast healthcare machine that benefits administration primarily. They have to use some system they didn't approve of, and they realize that the decisions in some sense aren't coming from them, they're being told what to do by administration. So rather than feeling like they're the top dog at the hospital, they're feeling like cubicle workers. That's what I suspect this is mostly about, not the time with patients, or whatever the hell the complaint du jour is. Note that on this point I sympathize with them--this administrative hierarchical model that's squeezing workers, whether it be healthcare, or IT, or education, or whatever, is fundamentally flawed. It's just new to physicians, or something they didn't think they'd have to deal with. This is my little tangential rant, but I'm sick of healthcare discussions in congress being so focused on costs, and not on deregulating healthcare and increasing transparency. There needs to be less of this kind of EHR red tape, more use of EHRs that is driven by their utility, more competition among provider models, greater consumer access to drugs and healthcare options (and I don't mean by giving them more money, I mean by letting them do whatever the hell they want), and more transparency about costs. Right now, we have a model where you have an extremely small number of people telling everyone else--including different types of providers, as well as consumers--what they can and cannot do with their own healthcare decisions, and billing them without them even knowing or agreeing to the cost of a service. Imagine if the government said that only accountants they approve of, with doctoral level finance degrees, could do your taxes, and that those accountants could charge whatever they want without telling you the cost ahead of time. People would be in an uproar. We spend all this time assuming that our healthcare system should basically stay as it is, but that we should reorganize how we pay for things, when the discussion should be about both.

twobyfour 9y ago

Were global (or at least nationwide) technical standards and specifications for data exchange protocols never defined as part of this mandate?

lbhnact 9y ago
No they were not. The quote, by David Blumenthal who designed the HITECH legistlation said this: "Before you can create interoperability, you have to create operability"[1] I'll leave it to you to decide whether this was a wise philosophy to underpin a major national IT project. [1]http://www.healthcareitnews.com/news/blumenthal-look-stage-1-meaningful-use-upshot-next-winter http://www.healthcareitnews.com/news/blumenthal-look-stage-1...
- dragonwriter 9y ago
  It seems to be the exact opposite philosophy that HIPAA originally took in the effort to get financial/administrative transactions to electronic formats, which was essentially that mandating interoperability would drive mainstream use.
nwhatt 9y ago
Nationwide yes - The program is commonly referred to as Meaningful Use. There were a number of requirements related to data exchange, and it moved the needle slightly. All the requirements are written as a numerator/denominator format. For example, 25% of all lab orders placed by a provider need to be resulted electronically. So there's an incentive to integrate some things, but not all. Edit: here are the 2015 rules and accompanying underlying standards: https://www.healthit.gov/policy-researchers-implementers/2015-edition-test-method https://www.healthit.gov/policy-researchers-implementers/201...
- lbhnact 9y ago
  Without bickering over MU requirements, you'd probably note that MU has been almost entirely ineffective at solving actual care problems with data exchange. Of 50 state exchanges, most have collapsed, with only occasional use of the ad-hoc implementations and networks that remain. And people dying everyday while vendors like ECW get wrist-slaps for lying to CMS about their MU compliance. -http://www.healthcareitnews.com/news/eclinicalworks-pay-155-million-settle-suit-alleging-it-faked-meaningful-use-certification http://www.healthcareitnews.com/news/eclinicalworks-pay-155-...

koolba 9y ago

For situations like this I wonder if it'd be easier/cheaper to hire a scribe to shadow the doctor. Compared to the doctor's salary, the cost of the scribe would be a rounding error. The doctor could scribble illegible notes or maybe take no notes at all, and the scribe could type up the details (either on the spot or after the fact).

markolschesky 9y ago
That's actually pretty common, especially for older physicians or high-volume specialists. There are also some companies working on solutions to automate this using in-room speech recognition technologies like https://iscribes.co/ https://iscribes.co/.

throwthisawayt 9y ago

My partner is a doctor who works at one the top medical systems in America. The EHR system she works is atrocious. Last time she asked me to look at it to help figure out how to print an image and I stared at this 90s era windows app that looked like the pied piper interface. I gave up after 15 minutes and we ended up screenshoting the image. Taleo felt like it had a better UX than it. I can't believe we let some of best doctors in the country waste hours each day fighting with terrible software instead of treating patients. My partner spends more time trying to figure out the EHR than she does treating patients.

xoail 9y ago

I am seeing this issue 2nd hand and I totally get it. My aunt runs a practice and her time with the patients dropped significantly. She is also unable to see as many patients as she used to before the mandate. While I've built few nifty tools (chrome extensions and macros) for her to simplify some of the cumbersome tasks, I am envisioning and planning to build a whole new EHR solution from scratch that puts doctors first, as my side project. It's a daunting task and requires expert domain knowledge. Hoping to get an MVP by end of year.

CabSauce 9y ago
Please build it around a standard (FHIR).
- xoail 9y ago
  Yes, this is so important and yet I see many EHR companies relax on it since its not heavily mandated.

hyperion2010 9y ago

Last time I went to see the optometrist (who keeps and all paper office) he told that he has started to see a huge uptick in fraud. How did he know? He started seeing records from certain docs where they did the full workup on every single patient. There is no way they could do this, a full workup takes between 5 and 7 hours (he said). So what was happening? Someone at these offices had filled out the 'full workup' form for their EHRs and then discovered that they now literally had a button that would print money (paid out by insurance companies). If you give someone a tool that lets them print money at the click of a button even if it means they didn't actually do all the tests to fill it in they are going to click it.

Johnny555 9y ago
Do you need EHR's to do this? Spending 30 minutes filling out paperwork documenting a fake 7 hours of work sounds like it's still profitable.
- hyperion2010 9y ago
  Most offices don't have someone with 30 minutes of their day to spare (per patient!), so if they are doing this they basically need someone dedicated to the fraud. Now it is 30 minute time cost up front and then they just select it from the dropdown box.

Skeletor 9y ago

This is the kind of thing that we are trying to fix at drchrono. I think legacy EMR interfaces that are heavily reliant on keyboard/mouse interfaces are too distracting. Mobility (iPad's for drchrono) are just starting to make a bigger impact on the market and I think over the next 5 years 80% of providers in the US will be using a mobile interface (probably an iPad) and not touching a keyboard/mouse while a patient is in the room.

walshemj 9y ago
how do you get round the sterility cleaning requirements I the UK all the pc's I see the doctors and ward staff using have special wipe clean keyboards etc>
- Skeletor 9y ago
  http://www.wikihow.com/Clean-Your-iPad http://www.wikihow.com/Clean-Your-iPad https://discussions.apple.com/thread/4383886?start=0&tstart=0 https://discussions.apple.com/thread/4383886?start=0&tstart=... I clean my personal iPhone/iPad once every few months. I think it's much easier and more possible to sterilize a glass/metal ipad than a keyboard (especially for onboarding of patients in a waiting room.)
- deleted 9y ago
  [deleted]

Johnny555 9y ago

AS a patient, I like Kaiser's EHR system -- the doctor talks to me, then pauses as he documents on the computer from time to time - he doesn't type while we talk. That doesn't seem noticeably worse than him staring at his clipboard while I'm talking with him. But the part I really like is that I have access to most test results online. And since Kaiser is a self-contained HMO and doesn't generally do referrals outside of their system, interoperability isn't really an issue -- when I get referred to a Kaiser specialist or move to a new area and start seeing a new doctor, I know they'll have access to my records. In a previous system, I had to see a specialist, and though they requested that my original doctor transfer all records, not all of the records were sent and I ended up having to reschedule an appointment so I could pick up the missing records and take with with me.