New Yorker: Why doctors hate their computers

[Rianne]

I just finished a master's in healthcare informatics and what you state above was proven by research. CPOE did save time for *everyone* in the clinical workflow *except* the MD. It increased the time for the MD.

I work in this area and have for many years....the promises made to Americans by the Health IT lobbying industry when the HITECH act was passed have not been fulfilled. In fact, several in the government let slip that they were most concerned about public health reporting and statistics and not necessarily better healthcare outcomes at an individual level. This is very sad to me because the technology has many times disabled the healthcare transaction between the patient and clinician. What you see happening now is a slow-down of the spend on Health IT because the federal government infusion is gone and now the technology must pay for itself or bring about a better overall ROI in the healthcare business model. So, the problem is not going to get solved soon, in my estimation.


And, yes, many MDs are getting burned out because ACA also dis-incentivized MDs being self-employed, so most are now employees and have to heed the dictates of their employer with regard to administrative tasks...hence the burnout.

I have an idea that will most likely go nowhere.

When I feel sick, while I'm at home, I can list my symptoms exactly. They are distinct and complete. When I get to the DR office, I forget half of them and cannot explain myself adequately. The DR feels rushed, I feel compelled to organize my thoughts and speak quickly.
What if I could submit my symptoms, concerns and questions ahead of time. The MD's assistant can scan for specific issues that matter. Half the time I don't know how to explain myself to the DR when I'm in the office.

The lack of understanding the symptoms last year, 2017, caused a major confusion and almost had me in the OR when I did not need surgery. There was confusion from Gallstones and a small bowel obstruction. I would have had my gall bladder removed unnecessarily and still had the obstruction which may have killed me.

My solution: submit symptoms and questions ahead of time via scan or lengthy phone call.

 

[sengsational]

I have an idea that will most likely go nowhere.

I have a lot of those. But in this case, help may just be at hand.


When I schedule an appointment, I do it online now, and they have a big box where you can type why you're coming. You don't have to select from choices that don't include what you're coming for, which is usually the case. So IF they read it, they'll be prepped for your less than eloquent presentation of symptoms.


It kind of worked for me...my doc said something that made me think he'd read what I wrote, and from then on, both of us had the understanding of the couple of sentences I wrote were the backdrop for our later in-person discussion.


One problem might be that they're "not getting paid to read your symptom description". In other words, they get paid when you and the doc are in the exam room, not before. But I'm sure (as the thread on medical billing indicates), they'll find a way to charge you for it!

 

[misshathaway]

The electronic health record did significantly increase the workload for me personally. I don't know about thoughts of suicide, but it certainly was a big incentive to retire early.

My primary care doctor, who was wonderful, knew that I had been in hospital IT before I retired. His network had converted to EPIC and he complained about it at every visit, and apologized when he had to take time out to input info during the visit. He did have an aide input the intake stuff but then he found mistakes in what the aide picked from the picklist for the "what meds do you take at home". For instance the aide had input a laxative instead of magnesium citrate supplement tablets. My PCP retired last year, alas. There were probably other factors but the computer time was part of it.

 

[Toocold]

I think part of the challenge is that every decision that a doc makes is scrutinized, so documentation has become more important than the practice of healthcare. The right clinical decision support tool can help. The wrong clinical decision tool with a bunch of unnecessary alerts makes it impossible. Can you imagine in your current or historical job, everything you do was micromanaged? I'd hate that.

 

[happy2bretired]

Most of us in our 60s had the joy of the computerization learning curve in our offices during our prime work years and we dealt with it, or were left behind. Doctors are in that same boat now.

Yep many of us dealt with it or it was “get left behind”. But, it was kind of an exciting time. I remember how excited I was when I received my first computer at work. All the changes that started happening, it kept my brain in thinking mode all the time. I went from being bored or thinking I was “in a rut” to being excited about learning something new.

 

[NW-Bound]

I think part of the challenge is that every decision that a doc makes is scrutinized, so documentation has become more important than the practice of healthcare. The right clinical decision support tool can help. The wrong clinical decision tool with a bunch of unnecessary alerts makes it impossible. Can you imagine in your current or historical job, everything you do was micromanaged? I'd hate that.

Some truth in that. Micromanaging is bad. But there has to be some kind of records of what has been done to the patients, so that the next doctor does not have to start from scratch. Engineers in their work leave behind blue prints, circuit diagrams, equations, etc... Same with accountants, lawyers, etc...

Maybe there's too much info? Gawande wrote about some doctors who just cut and pasted the same info onto every patient's record, and it becomes meaningless. These are terrible doctors.

As Gawande wrote,

... As the chief clinical officer at Partners HealthCare, Meyer supervised the software upgrade. An internist in his fifties, he has the commanding air, upright posture, and crewcut one might expect from a man who spent half his career as a military officer...

“But we think of this as a system for us and it’s not,” he said. “It is for the patients.”

If the software is bad, then solicit doctors' inputs and change it.

 

[gerntz]

Records available to a wide range of people offer the possibility of an overlooked diagnosis over time. Entering health data has to be a good thing to me. Entering administrative data is another subject.

 

[Clone]

I had some surgery last Monday. Monday morning, no less than 4 times (while I was hooked up to an IV), I had a person stop in, scan their card on the computer, scan my wristband, and then ask me to go through my list of medications. The list of meds on the computer was OK, it had been verified at least 6 times in the prior week!



I see advantages in the electronic system, as multiple folks have equal and transparent access to the information. Once I had verified that the list of meds in the computer was correct, it did not need to be transcribed from my handwritten notes the next 9 times (even though several of the folks still wanted to recreate the list from scratch).



I imagine that a number of the folks see no-value-added activity when they are required to 'scan-in, scan patient, check box, log-out' multiple times per hour. Eventually, these systems get streamlined.

 

[aja8888]

I had some surgery last Monday. Monday morning, no less than 4 times (while I was hooked up to an IV), I had a person stop in, scan their card on the computer, scan my wristband, and then ask me to go through my list of medications. The list of meds on the computer was OK, it had been verified at least 6 times in the prior week!



I see advantages in the electronic system, as multiple folks have equal and transparent access to the information. Once I had verified that the list of meds in the computer was correct, it did not need to be transcribed from my handwritten notes the next 9 times (even though several of the folks still wanted to recreate the list from scratch).



I imagine that a number of the folks see no-value-added activity when they are required to 'scan-in, scan patient, check box, log-out' multiple times per hour. Eventually, these systems get streamlined.

I would guess that every time your wristband gets scanned, a charge gets generated too!

 

[6miths]

If the software is bad, then solicit doctors' inputs and change it.

This would be the ideal but in my experience not what is happening at least not in a useful way. These products are developed to be sold and once a health system or office has committed to them further development is not necessarily cost effective for the entity that has developed them. Many of the products were rushed to market with the knowledge that once administration has made a decision they are not going to be able to easily change direction even if a much better product comes along. There is not much flexibility or customizability in the products and of course they generally do not interact with each other well.

 

[braumeister]

There is not much flexibility or customizability in the products and of course they generally do not interact with each other well.

That's what happened to my last doctor's office. The software they had been using was unable to export the data to any other system. They had to manually copy everything as if it were brand new data, and it took them months.

 

[jimbee]

That's what happened to my last doctor's office. The software they had been using was unable to export the data to any other system. They had to manually copy everything as if it were brand new data, and it took them months.

Yep, I ran into this during my last physical. I changed medical networks this year. The person updating my data at my new clinic could access my medical data from my old clinic, but had to enter the data by hand. I told him I was able to download the data from my old clinic in XML format, specifically intended to make data transport like this more automatic. He said they weren't able to access/import the data in that way.

 

[Vacation4us]

Epic sucks period. It does not flow like a paper chart. It's difficult to find anything in it. It definitely slows things down and takes time away from taking care of a patient.

As a Labor and Delivery nurse I can personally tell you that EPIC was not designed to make anything simpler. Before Epic a Labor flow sheet was 3 pages. Had to go to the OR 1 page, PACU 1 page, done. Your focus was the patient 90 % of the time with 10% paperwork. Now at least 70% is EPIC and 30% is hands on.

Daylight savings time OMG, we had a birth during that duplicate hour no place to chart during that hour. Like it doesn't exist. There are also several ways to "find" the same task in EPIC which only makes it more difficult to master. Once you input the information you can't see all the past information at a glance which makes it very difficult to see if you missed putting in everything. I could go on and on.

EMR is good in theory EPIC is a shi* show.

 

[marko]

In recent years, Doctors have had to spend more time and more time in administration instead of being a doctor.

This is the number one reason my doctor stopped taking insurance and joined the Direct Care world.

He realized that he was paying 3 people who's only job was to keep insurance straight and the cost was equal to what he was getting from insurance. Plus he was limited to how long he could spend with a patient.

Now, he charges me $100 a month, doesn't take insurance at all, has one receptionist and one nurse and can spend an hour with me if he wants (and he has).

 

[NW-Bound]

Besides the $100/month, what does your doctor charge per visit?

Yes. In an ideal world, everyone would have a concierge-style healthcare with a personal physician. The only way that can happen is if we can turn out lots of doctors, and make them work for peanuts.

 

[marko]

Besides the $100/month, what does your doctor charge per visit?

Yes. In an ideal world, everyone would have a concierge-style healthcare with a personal physician. The only way that can happen is if we can turn out lots of doctors, and make them work for peanuts.

Nothing.

For $100 a month I get 10 doctor visits, an annual physical, Skype and email access for minor issues and, for $30, he'll make a house call. He charges me $12 for blood tests. He can, and does spend upwards of 45 minutes to an hour with you if necessary. My last physical last month lasted an hour and fifteen minutes as we went over meds, BP, eating, history, concerns etc.

I generally can get an appointment within a few hours and he, himself will call me with lab results etc.

It's not a concierge service which charges your insurance on top of the fee.

Check out https://www.dpcare.org/ for info on Direct Primary Care which is what my doctor is doing.

He limits his practice to 650 patients vs his old 2500 and claims he now has more time, more personal time and is making more money than when he was part of a 'health partnership' group.

 

[NW-Bound]

Wow, that's not bad. It is not economical for me, who only sees a doctor twice a year, and that is to get renewed script for my medicine for essential high blood pressure. When I get older and have to see a doctor more regularly, a level of personal care like this is good.

Come to think of it, at $1200/yr per patient, can a doctor make enough to pay rent, insurance, and staff with a list of 300 patients? 400?

 

[MRG]

Yep, I ran into this during my last physical. I changed medical networks this year. The person updating my data at my new clinic could access my medical data from my old clinic, but had to enter the data by hand. I told him I was able to download the data from my old clinic in XML format, specifically intended to make data transport like this more automatic. He said they weren't able to access/import the data in that way.

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


Health Level-7*or*HL7*refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is "layer 7" in the*OSI model. The HL7 standards are produced by the*Health Level Seven International, an international*standards organization, and are adopted by other standards issuing bodies such as*American National Standards Institute*and*International Organization for Standardization.

 

[urn2bfree]

Seems we know what priorities there are when it comes to handling information about various topics:

I can go to an ATM from a bank different than mine, in another country, and instantly look at my financial information.

For years doctors handwriting was notoriously bad such that pharmacists were famous for deciphering prescription scribbles- and yet when you write a check you not only write the money amount in number form but must duplicate it in written out word form.

I haven't bought a house recently, but if it is the same as it was 7 years ago it involves personally signing and initialing triplicates of huge stacks of paper. Anybody working to streamline that process into a computer format?

 

[MRG]

I haven't bought a house recently, but if it is the same as it was 7 years ago it involves personally signing and initialing triplicates of huge stacks of paper. Anybody working to streamline that process into a computer format?

The big players all have automated technology for loan origination. I'm not sure how far they've pushed peripherals into the user experience, but the back office is automated with business process management tools.

 

[audreyh1]

I have an idea that will most likely go nowhere.

When I feel sick, while I'm at home, I can list my symptoms exactly. They are distinct and complete. When I get to the DR office, I forget half of them and cannot explain myself adequately. The DR feels rushed, I feel compelled to organize my thoughts and speak quickly.
What if I could submit my symptoms, concerns and questions ahead of time. The MD's assistant can scan for specific issues that matter. Half the time I don't know how to explain myself to the DR when I'm in the office.

The lack of understanding the symptoms last year, 2017, caused a major confusion and almost had me in the OR when I did not need surgery. There was confusion from Gallstones and a small bowel obstruction. I would have had my gall bladder removed unnecessarily and still had the obstruction which may have killed me.

My solution: submit symptoms and questions ahead of time via scan or lengthy phone call.

I write this stuff down plus list questions ahead of time. Take the printed notes to the doctor visit.

If there is a lot going on - I may even journal it. Track my daily symptoms and record them.

 

[swakyaby]

Epic sucks period. It does not flow like a paper chart. It's difficult to find anything in it. It definitely slows things down and takes time away from taking care of a patient.

As a Labor and Delivery nurse I can personally tell you that EPIC was not designed to make anything simpler.

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.

 

[pacergal]

EPIC challenges was one reason I did not mind retiring. Yes, computerized HC records are good for easy access to care over multiple health facilities, but our EPIC system had updates every month! Then our IT dept. had to show us work arounds, because that particular update did not work with the version we had!! So frustrating. If you are going to buy into a computerized system, buy the whole d*** thing, not bits and pieces.

 

[MRG]

I spent some time and read that article. Man am I glad I'm retired!

I do understand many of the points made. I spent many years introducing similar technology in different markets. Some of the authors comments are really just documented human behaviors.

It did crack me up to be reading about "The Mythical Month", still a classic..

 

[JoeWras]

Yeah, glad I retired too. Actually, these kinds of issues are exactly what has turned me off on tech. I was the creator of systems like this, not specifically EPIC, but as the article mentions, there are numerous other systems that suffer the same problems.

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

If I had to extract one snippet from the article that weighs on my mind, and both my place in technology, and the thing that started bugging me about my job, it is this:

As I observed more of my colleagues, I began to see the insidious ways that the software changed how people work together. They’d become more disconnected; less likely to see and help one another, and often less able to.

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.