New Yorker: Why doctors hate their computers

[marko]

Additionally, the depersonalization of using computers weighs on my mind. Facebook, for example.

This is not just a problem with doctors, it is a problem with all of us in society that becomes dependent on using "devices" as an intermediary in our communication.

Slightly off topic, but waaaay back in the day, the phones in our office slowly stopped ringing as email and online sales of our products started becoming the norm.

What had been almost a cacophony some days became near silent offices as people stopped talking to each other and instead fired off emails.

 

[ExFlyBoy5]

Helping take care of my Dad over the last couple of years of his life, I saw the difference in providers that were part of a large network medical provider as well as providers that were sole practitioners that had been doing it for 40+ years (and little computer use with the patient in the room). My observation was that the providers who were part of the large system gave good care and while they were doing computer inputs during the appointment, it wasn't so egregious as to detract from what Dad was there for. Follow ups were much better too...the provider was able to read a quick summation on the screen (and any applicable labs that may apply) which made the appointments worthwhile. HOWEVER, in the case of the solo practitioner, his care was substandard and in my opinion borderline malpractice. 3/4 of the appointment time was spend re-hashing the same, irrelevant information from previous appointments and having to remind the provider about how meds had been adjusted/etc. He would thumb trough a large paper file for a minute at a time and could never "find" what he was looking for. Ultimately, it was to the detriment to my Dad's quality of life the last couple of months and well...I could go on and on. Bottom line..between the experiences with my Dad and my previous primary care clinic being a paper-rich environment, I will take an automated office any day of the week.

This is not to discount that there are growing pains with the technology. I get it. Change is hard.

Lastly, the author of the article now has a large role in the new health care "organization" that is being organized by some of the richest people in the world. While I know Gawande is a very smart man, I can't help but think that there may be some $$$ in a "new and improved IT system" and I am sure some of that will go in the pockets of these very rich individuals.

 

[AS2019]

Many valid points above. As a physician, I can tell you that it is frustrating. The EMR is fantastic for looking at a patients record. The old was was to call down to central records and have them search for it and send it to you. Many times the patient record couldn’t even be found. They frequently got lost. So am EMR makes it easy to see all of the record from a remote location. Multiple providers can access the record at the same time. Also, there are some efficiencies, if set up right. If Dr. A orders a lab test and 6 hours later Dr. B order the same lab test, then the EMR can cancel the duplicate test, saving money. There are plenty of efficiencies like that.

But there are a ton of inefficiencies. Government regulations require that a patient’s medication list be reviewed by each provider. Therefore it’s built into the rules of the EMR. So you get asked 6 times In a row what medications you’re taking.

As for copy and paste, that’s nothing new. Before the EMR, the physician simply dictated “standard report format” or a similar phrase, and the transcriptionist typed a standard form. Now it’s done by the provider using copy/paste. The primary reason for that is insurance and Medicare require certain language to be in every report. If it’s not, then they either don’t pay you, citing an incomplete report, or they charge you with fraud for billing for a service which isn’t properly documented.

I could go on all day about this. But just keep in mind that most of the things that seem ridiculous to the patient also seem ridiculous to the physician. However, the physician is powerless to fix it. As for “asking the physicians how to make the EMR more functional and then fixing it”, well I guess that’s like saying “Microsoft should just ask me what’s wrong with Windows and then fix it”.

I better get off of my soap box before I decide to just retire and be done with it. Oh wait, too late for that.

 

[NW-Bound]

At my hospital as well, Epic was the electronic health care record (EHR) interface we all had to deal with. After EHR, I noticed it took 2 labor and delivery RNs in the operating room for a Cesarean section to perform the duties it formerly only took one—one to attend to the surgery, and one dedicated solely to sitting at the computer screen inputting all the data the EHR required. Very time-intensive for doctors and nurses.

Wow, that's pretty bad! What is the data they want?

Do they really want a "blow-by-blow" reporting of what is going on in the OR? Why can the medical monitoring equipment not be electronically interfaced to log pulse rate, blood pressure, etc..., every minute if that is desired? Videotape the operation so they can review if they feel like it?

Many valid points above. As a physician, I can tell you that it is frustrating. The EMR is fantastic for looking at a patients record. The old was was to call down to central records and have them search for it and send it to you. Many times the patient record couldn’t even be found. They frequently got lost. So am EMR makes it easy to see all of the record from a remote location. Multiple providers can access the record at the same time. Also, there are some efficiencies, if set up right. If Dr. A orders a lab test and 6 hours later Dr. B order the same lab test, then the EMR can cancel the duplicate test, saving money. There are plenty of efficiencies like that.

But there are a ton of inefficiencies. Government regulations require that a patient’s medication list be reviewed by each provider. Therefore it’s built into the rules of the EMR. So you get asked 6 times In a row what medications you’re taking.

As for copy and paste, that’s nothing new. Before the EMR, the physician simply dictated “standard report format” or a similar phrase, and the transcriptionist typed a standard form. Now it’s done by the provider using copy/paste. The primary reason for that is insurance and Medicare require certain language to be in every report. If it’s not, then they either don’t pay you, citing an incomplete report, or they charge you with fraud for billing for a service which isn’t properly documented...

These requirements, if unduly, are not a function of the EMR as I can see, but rather a bureaucratic burden that is perhaps easily demanded and enforced with an EMR. Red tape can exist without EMR too.

I could go on all day about this. But just keep in mind that most of the things that seem ridiculous to the patient also seem ridiculous to the physician. However, the physician is powerless to fix it. As for “asking the physicians how to make the EMR more functional and then fixing it”, well I guess that’s like saying “Microsoft should just ask me what’s wrong with Windows and then fix it”.

I better get off of my soap box before I decide to just retire and be done with it. Oh wait, too late for that.

Is there a monopoly with EMR? Even though Microsoft software is ubiquitous, there are still alternative choices, such as software from Apple, and freeware from Linux. Word processing software may have bugs, but we cannot go back to the IBM Selectric now.

 

[AS2019]

NW-Bound, I'll answer your last question first. There isn't a monopoly, but there is an oligopoly. There are a few big software companies that produce EMRs. You can build your own if you want, but it has to communicate/interface with multiple other EMR's, laboratory information systems, all of the equipment, radiology software, billing software, etc. It's just too overwhelming for most hospital systems to invest that kind of money to build their own. So you're stuck with one of the few "off-the-shelf" packages out there. To give you some idea, Epic for a medium sized hospital can cost hundreds of millions of dollars to purchase and implement. No hospital has an IT department capable of building something on that scale from scratch.

As for the documentation requirements, you're also correct that these aren't direct functions of the EMR. What has changed is that 1. The documentation requirements grow year after year. They never get simpler - only more complex. Adding a few items this year, and a few more next year, etc. It's a nickel and diming process where you add a minute here and a minute there, and by the end of the day, it adds up to hours. 2. This is all being shifted to the provider. Where we previously had transcriptionists, assistants, nurses, etc, to perform these tasks, now the provider has to do it. Again, nickel and diming their time.

There are always ways to improve the efficiency. The medical field is just decades behind in the area of IT. Up until a few years ago, the EMR was literally a digital version of a paper chart. You could get the same end product by simply scanning in paper documents. Only in the past few years have the EMRs become more functional. Epic, for all its faults, does a decent job of "automating" at least some of the functions. If you prescribe two medications which have an adverse reaction on one another, then it blocks the order (as long as the pharmacy portion has that rule written in). You can 'customize' it to your particular order sets, make hot-keys to autofill some fields, import data from the radiology report into your note, etc. But it is nowhere near as slick as Facebook or Amazon, which seem to know more about me that I know about me.

Again, I could go on for hours. Someday, it will all be worked out and it will be fine. Currently, it's rather painful.

 

[Walt34]

Again, I could go on for hours. Someday, it will all be worked out and it will be fine. Currently, it's rather painful.

I had a late afternoon appointment with my PCP today, and I briefly mentioned the article. He agreed that the software is a work-in-progress in that some things are in fact faster and easier, others, not so much.

 

[NW-Bound]

Like many things that are mandated, the intention and goal are good, but the implementation always leaves some bad tastes in your mouth. Like ACA.

Let's hope that things will get improved with time. And that you are not a casualty of its unintended consequences.

 

[AS2019]

Nah, I'm not a casualty of the EMR and/or ACA. They're annoying, but all industries have their annoyances. I'm just bored and ready to do something else for a while.

 

[target2019]

Why Doctors Hate Their Computers

I changed GP about a month ago. At my first visit, the switch was confirmed, as a much younger MD was more in command of the visit. With previous MD (much older) there were many instances of unawareness.

I asked the new GP, who had to spend a lot of time reviewing the many entries in my health record, how did she view the system, which pretty much just presents a list of results, and you have to open each in turn to see the result. That is very inefficient, IMO.

Her response was that it just takes time to review the specifics, and nothing in the system alerts her to anything specific that needs to be addressed. The test must be opened. She mentioned that specialists involved usually send her a communication about anything urgent.

My new doc does not hate the computer, and seemed ok with reading results and speaking with me at same time. Previous GP could not do that.

 

[swakyaby]

Wow, that's pretty bad! What is the data they want?

Do they really want a "blow-by-blow" reporting of what is going on in the OR? Why can the medical monitoring equipment not be electronically interfaced to log pulse rate, blood pressure, etc..., every minute if that is desired? Videotape the operation so they can review if they feel like it?
.

No, the MD or CRNA documents the vital signs in the EHR. What the second RN does at the computer is a documentation nightmare required by EPIC. I’m not sure exactly what they’re typing, but I see them log in about 5-10 minutes prior to the patient entering the room, click the exact time the patient enters the OR room, curse because EPIC automatically logged them out, re-log in while the patient is being prepped, continue typing and documenting who knows what, document time out of the room, and return to the computer after surgery to complete the nursing record for 5-10 more minutes to close the record.

Paper records were never that labor-intensive in the OB room.

 

[Sue J]

Here is an EMR issue that I'm dealing with.

My Primary Care Physician is married to a specialist surgeon. She is in a Family Practice that is in my network. Her husband works for a specialty practice nearby that is out of my network.

Somehow, her husband keeps showing up as my physician in my records. I've had this happen twice now and I've caught it and had it corrected. I imagine that someone is clicking a dropdown box and clicking on the wrong doctor.

This is just plain stupid! And I, the patient, am the only one paying attention to this!

 

[NW-Bound]

No, the MD or CRNA documents the vital signs in the EHR. What the second RN does at the computer is a documentation nightmare required by EPIC. I’m not sure exactly what they’re typing, but I see them log in about 5-10 minutes prior to the patient entering the room, click the exact time the patient enters the OR room, curse because EPIC automatically logged them out, re-log in while the patient is being prepped, continue typing and documenting who knows what, document time out of the room, and return to the computer after surgery to complete the nursing record for 5-10 more minutes to close the record.

Paper records were never that labor-intensive in the OB room.

I wonder how much of the pain is caused by buggy software, poor user interface, and a slow computer. In other words, the info to be typed in may not be so onerous, but the computer makes it a lot worse.

Don't know about EMR, but I have experienced horrible software that makes me want to jam my fist into the screen or pound the keyboard to break it in half. I am sure there are more and more incompetent programmers being employed now, as computers are used in every aspect of our life and they run out of good IT workers.

 

[MRG]

I wonder how much of the pain is caused by buggy software, poor user interface, and a slow computer. In other words, the info to be typed in may not be so onerous, but the computer makes it a lot worse.

Don't know about EMR, but I have experienced horrible software that makes me want to jam my fist into the screen or pound the keyboard to break it in half. I am sure there are more and more incompetent programmers being employed now, as computers are used in every aspect of our life and they run out of good IT workers.

When I was w*rking around this type of technology the mantra was "if a human doesn't add value to the process, automate that job". Not sure how a valuable person like a nurse looking at one system and adding it's data to a different system is using that person's skills? Seems like the machines could talk, perhaps I don't understand the problem? Of course all of the people who didn't add value were now redundant.

 

[GrayHare]

After the horror of 1980s user interfaces, Xerox and Apple promulgated a better way with mice, and pull-down menus, and help systems. And we saw that it was good. Then came hand held devices with small screens, with no room for all that UI, and with touch screens for people with fingers wider than a mouse pointer. No problem! Easy to learn app builder software for those devices meant people could quickly cobble crappy apps (crapps). What we learn from history is that no one learns from history. The '80s are calling and they want their software back.

 

[deserat]

Yeah, that pesky proprietary XML. Too bad there's no standard for it in healthcare![emoji12] [emoji12] [emoji12]
https://en.m.wikipedia.org/wiki/Health_Level_7

Rant on/

HL7 is a joke when one wants the true data...it's an envelope and if the information in the letter is not using data standards, it is still proprietary. Right now the hot thing is "FHIR." It is merely a resource locater - i.e., it 'webizes' access to supposed data resources, but again, that data is in proprietary format.

They are now building a 'stack' to support FHIR and HL7 is on board....and yet, the data is still not in a standard format (except for public health reporting). I just got back from a client visit - all of their clinical information system interfaces are using a pdf transfer.....and the data in the flow sheets is in ****** vendor proprietary format.

In the end, the acquirers are going to need to demand that things become interoperable and usable. While I do believe that using computers in general can make many things better, in the case of EMR/EHRs and clinical workflow it has been proven by research the clinicians have gotten the shaft in much of the implementations. And it is not just the older clinicians that are complaining...it is the younger ones, too.

The Health IT industry has a lot to answer for on this. Interestingly, I was on a group evaluating proposals for US funding of Health IT projects and it turned out one of the other people in the group was the CEO for HL7. I made a few derogatory comments regarding the medical device aspect of the FHIR and HL7 standards and he agreed. So, it's a known problem and a huge barrier to true interoperability.

What I find very sad is the people telling the clinicians to just "snap out of it." I had a similar experience when I was working for a very large healthcare organization - the IT people kept telling us and the clinicians to 'snap out of it' and just do what they wanted when they wanted it. Turns out the IT people had never visited an ICU or clinic and didn't understand how disabling the introduction of their particular technology would be to the delivery of healthcare. I was constructive and set up a 'walk-through' for the IT people and jokingly asked the nurse to make sure a patient crumped, had a code with a crash cart needed and some blood thrown around for extra drama. To be fair, the IT people came away with a much better understanding and were much more amenable after that.

/Rant off

 

[misshathaway]

Yeah, that pesky proprietary XML. Too bad there's no standard for it in healthcare![emoji12] [emoji12] [emoji12]
https://en.m.wikipedia.org/wiki/Health_Level_7

In the end, the acquirers are going to need to demand that things become interoperable and usable. While I do believe that using computers in general can make many things better, in the case of EMR/EHRs and clinical workflow it has been proven by research the clinicians have gotten the shaft in much of the implementations. And it is not just the older clinicians that are complaining...it is the younger ones, too.

I worked in a large healthcare system doing interfaces. There was LOTS of work b/c virtually every department had their own completely homegrown or vendor-made but customized system. Those clinicians were not inclined to switch to some generic system after perfecting the one they were using, and they held a lot of sway. The IT dept. had to be large to support all of those systems and the interfaces between them. The IT dept heads, central in making software purchase decisions, also had a vested interest in keeping their jobs maintaining the world's largest Rube Goldberg machine.

I don't think that system will ever get Epic, even though it would have increased interoperability and decreased support costs. But would the clinicians eventually have gotten used to Epic? I'm not so sure now. At the time I viewed it as a physician ego thing, not as concern over quality of care.