New Yorker: Why doctors hate their computers

[Walt34]

Interesting article about the computerization of health care records and some unintended consequences. I've seen some of this myself during doctor visits, when the doctor is looking at the screen more than me. The system isn't ready for prime time yet.

The article is a bit long but I think it is worth the read.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers

More than ninety per cent of American hospitals have been computerized during the past decade, and more than half of Americans have their health information in the Epic system. Seventy thousand employees of Partners HealthCare—spread across twelve hospitals and hundreds of clinics in New England—were going to have to adopt the new software. I was in the first wave of implementation, along with eighteen thousand other doctors, nurses, pharmacists, lab techs, administrators, and the like.

But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.

 

[Gumby]

The young wife was a volunteer EMT for 25 years. Perhaps the principal reason she stopped was the intrusion of the computer. It was frustrating and inefficient to deal with while she was on the ambulance trying to take care of the patient, and she would need to spend hours after her shift getting the computer records straight.

Computers were sold to us as a tool to make life better. They often make it worse.

 

[braumeister]

I can certainly understand the frustration, but there seem to be ways of getting around it. I can think of a few doctors we have seen in the last five years who have essentially avoided computer involvement beyond looking at patient records.

What they do is dictate their notes, generally while in the room with the patient. One of them speaks so rapidly that requires your whole attention to follow him, but it's still clear and distinct.

Obviously that means extra staff to transcribe those dictated notes into the computer, which increases the cost, but it makes the doctor's time so much more efficient.

 

[RAE]

Yes, it's obvious every time I go for a doctor appt. now that the docs are frustrated with the amount of time they have to spend entering data into the PC, or checking lists of lab tests to find the one they want, etc.. It really does cut into the time they are able to spend interacting with patients. Something is wrong when we are paying highly-trained professionals to do data entry rather than communicating with their patients.

 

[GrayHare]

Something is wrong when we are paying highly-trained professionals to do data entry rather than communicating with their patients.

Agree for data entry, but for retrieval the doctor will need to search the records in the computer.

IMO a large part of the difficulty is that computer-based records too often lack obvious reference points and cues. When I have a physical folder of papers, after time I develop a "feel" of where individual items are kept because I remember an item's physical location within the folder. On the computer there are fewer visual cues, and zero physical ones.

 

[urn2bfree]

Something is wrong when we are paying highly-trained professionals to do data entry rather than communicating with their patients.

Computers are improving patient care in some cases, for example speeding up the time from order entry to order fulfillment. However, this is being accomplished at reduced cost by extracting more work from the doctors... Data and order entry by another person would mean an extra full time employee with the added expense of benefits. Dump these tasks on the doctors who are already compensated so well they have no right to complain. So what if the doctor has to spend more time if it can be sold as improving time to patient care?
Result- unhappy doctors, more than half of whom would quit if they could, in many surveys. It was certainly one of the heavier straws that broke my career camel's back. Rarely did a month go by without another dictate from on high informing me of another task they were dumping on us doctors. ("It's just a few extra computer clicks." They tell you- oblivious that they these extra clicks are on top of the few they added last month and the few they will add next month. And completely unaware that each new extra set of clicks is for each patient- so multiply it over multiple encounters.)
And all this extra work was added on to a profession that was already regularly pulling 60-80 hour work weeks BEFORE the additional work was added.

 

[corn18]

My wife was visiting her otho surgeon after knee surgery. Had a newbie do the pre work and get her records up. Then he came in and had google glass on. There was a guy in India doing real time transcribing of the visit. That was weird. But efficient.

 

[Oz investor]

Computers are improving patient care in some cases, for example speeding up the time from order entry to order fulfillment. However, this is being accomplished at reduced cost by extracting more work from the doctors... Data and order entry by another person would mean an extra full time employee with the added expense of benefits. Dump these tasks on the doctors who are already compensated so well they have no right to complain. So what if the doctor has to spend more time if it can be sold as improving time to patient care?
Result- unhappy doctors, more than half of whom would quit if they could, in many surveys. It was certainly one of the heavier straws that broke my career camel's back. Rarely did a month go by without another dictate from on high informing me of another task they were dumping on us doctors. ("It's just a few extra computer clicks." They tell you- oblivious that they these extra clicks are on top of the few they added last month and the few they will add next month. And completely unaware that each new extra set of clicks is for each patient- so multiply it over multiple encounters.)
And all this extra work was added on to a profession that was already regularly pulling 60-80 hour work weeks BEFORE the additional work was added.

having made a hobby out of computers , i am amazed at user expectations , of 'a simple easy extra task ' .. for a starter those extra 'clicks' require full concentration ( look at some of the epic 'fat finger ' trading events as a disclosed example ).

also the assumption the machine answer is always correct, can lead to terrible consequences .

 

[Bamaman]

In recent years, Doctors have had to spend more time and more time in administration instead of being a doctor. They don't care that Big Daddy is dictating to them how to handle medical issues and treatment when Big Daddy is not a healthcare professional.

Sure, computers should make healthcare more efficient, including quicker and smoother administration. And computerized billing should get the doctor's insurance and Medicare payments faster. But the amount of money they're getting for blood tests and handling of test samples borders on slave wages.

We're living in a low cost of living city, and our doctors are not paid nearly as much money for Medicare paybacks as doctors in larger medical markets. It's just a pittance of what the office visits are worth for Family Practice and Internal Medicine offices. But if a doctor is a nephrologist, Medicare pays them big, big money. Things are inconsistent.

My doctor never did handle paperwork very well. You certainly couldn't read his writing. He obviously never learned to type, and watching him write into a laptop is downright comical. He's just fumbling on electronic medical systems. But at about age 65, he's made no secret that medical records and the new way of doing business is going to make him want to retire early.

 

[deserat]

Computers are improving patient care in some cases, for example speeding up the time from order entry to order fulfillment. However, this is being accomplished at reduced cost by extracting more work from the doctors... Data and order entry by another person would mean an extra full time employee with the added expense of benefits. Dump these tasks on the doctors who are already compensated so well they have no right to complain. So what if the doctor has to spend more time if it can be sold as improving time to patient care?
Result- unhappy doctors, more than half of whom would quit if they could, in many surveys. It was certainly one of the heavier straws that broke my career camel's back. Rarely did a month go by without another dictate from on high informing me of another task they were dumping on us doctors. ("It's just a few extra computer clicks." They tell you- oblivious that they these extra clicks are on top of the few they added last month and the few they will add next month. And completely unaware that each new extra set of clicks is for each patient- so multiply it over multiple encounters.)
And all this extra work was added on to a profession that was already regularly pulling 60-80 hour work weeks BEFORE the additional work was added.

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.

 

[swakyaby]

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.

 

[NW-Bound]

My late father, before his death, was in/out of hospitals all the time for various reasons. When they wheeled him around from one area of the hospital to another, his files traveled with him in the form of a big folder with papers of about 1-in thick. On one occasion, I started to pick up that folder and look through it to see what it contained out of curiosity, and the nurse gently warned me that it was hospital record and if I wanted to see it I needed to make a formal request.

This was in 2003. That incidence made me wonder about the purpose of that traveling folder. If doctors needed to look it up for medical information about my father's case, I doubted that they could find relevant info among that 1" thick ream of papers. What if they missed something? And these sheets of paper that I was not allowed to look through were printed forms. So, they already existed on a computer somewhere. What the heck?

It seemed to me a better computer record would allow them to easily see what previous doctors had done for my father. But now, I am told computers do not help.

 

[NW-Bound]

My wife was visiting her otho surgeon after knee surgery. Had a newbie do the pre work and get her records up. Then he came in and had google glass on. There was a guy in India doing real time transcribing of the visit. That was weird. But efficient.

I just looked that up. From Wikipedia article on Google Glasses:

Augmedix developed an app for the wearable device that allows physicians to live-stream the patient visit and claims it will eliminate electronic health record problems, possibly saving them up to 15 hours a week and improving record quality. The video stream is passed to remote scribes in HIPAA secure rooms where the doctor-patient interaction is transcribed. Ultimately, allowing physicians to focus on the patient. Hundreds of users were evaluating the app as of mid-2015.

My niece worked as a medical scribe while trying to get admission to a medical school. I did not know what her job was, and had to look that up. She was working closely with the doctors in an ER, and I think had to follow them around to record the work they performed on the patients.

 

[Clone]

The medical industry is going through the same in-efficiency and bs caused by computerization of the workplace that many of us lived through in other industries. New systems are implemented (always sold as being an improvement, more efficient, and more secure). Yet all of the old requirements are still in place (you still need to document everything by hand, the downstream user can't pull the data, you need to create the report for them) support staff is minimized because the new system is promised to be more efficient. And the system probably goes through multiple iterations before anything becomes stable. Folks calling the shots do not necessarily understand the business, while others realize everything must be redundant because we can not tolerate any risk.


I think that there will be benefits in the future because of better documentation and follow-up. But the systems today are not even close. Some folks can see where they are getting better, but the implementation is still on the first steps of true process integration.


And I am sure that many physicians are fed up with the workplace. Just like many of us have dealt with frustrating workplaces.

 

[pjigar]

Change is always hard. My background is in semiconductor industry where we used to draw circuits (and PCBs) by hand in not too distant past. Learning to use computers was hard and frustrating. But after everyone mastered the process, computers are helping us big time in creating ever more complex systems-on-ship (SoC).

I envision computers will be able to do similar lion's share of lifting once all the data is in the system (auto-advising, inter-discipline evaluations, drug interactions, etc.).

True story: I had pain in my arm, loss of strength, neck MRI confirmed disc herniation, doctor performed TDR surgery and pain is still there! The physical therapist suggested I consult a shoulder doctor. Shoulder doctor diagnosed bursitis. I could have avoided/delayed neck surgery had my neck specialist was advised by someone about the adjoining discipline and possibility of bursitis.

 

[NW-Bound]

Interesting article about the computerization of health care records and some unintended consequences. I've seen some of this myself during doctor visits, when the doctor is looking at the screen more than me. The system isn't ready for prime time yet.

The article is a bit long but I think it is worth the read.

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers

The author of this article is Atul Gawande, whose book "Being Mortal" I have read. I looked through the article, and here's my impression of the causes that Gawande identified.

First, the software is not well designed. It forces the users to enter in basic data that could have been defaulted.

“Ordering a mammogram used to be one click,” she said. “Now I spend three extra clicks to put in a diagnosis. When I do a Pap smear, I have eleven clicks. It’s ‘Oh, who did it?’ Why not, by default, think that I did it?” She was almost shouting now. “I’m the one putting the order in. Why is it asking me what date, if the patient is in the office today? When do you think this actually happened? It is incredible!”

The above doctor added that doing more work did not bother her. It was the pointlessness of it.

Secondly, the system was slow, and it took too long for doctors to look up some info. That explains why they spend time staring at the computer screen instead of talking to patients. And then, the software has flaws, such as not being able to handle daylight saving time switching. The computer could not handle the clock being reset. The period of 1:00-1:59AM was getting duplicated, and the computer had no way of recording information for hospital activities during that period.

These kinds of technical problems will go away with time, but Gawande identified a tougher problem. The system now forces medical providers to collaborate, and that always causes conflict.

Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called “the Revenge of the Ancillaries.” In building a given function—say, an order form for a brain MRI—the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn’t even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with “field required” alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.

And finally medicine is a complex field, and doctors do not always agree (that's why we are advised to seek a 2nd opinion). If doctors did not have enough info about the patients before, now they have too much. It takes time to dig out the relevant info, to find the wheat among the chaff.

Each patient has a “problem list” with his or her active medical issues, such as difficult-to-control diabetes, early signs of dementia, a chronic heart-valve problem. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. Sadoughi used to keep the list carefully updated—deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient (“pain in leg”), which is sufficient for billing purposes but not useful to colleagues who need to know the specific diagnosis (e.g., “osteoarthritis in the right knee”). Or someone will add “anemia” to the problem list but not have the expertise to record the relevant details; Sadoughi needs to know that it’s “anemia due to iron deficiency, last colonoscopy 2017.” The problem lists have become a hoarder’s stash.

Can these tougher problems be worked out? I don't know. Doctor's inputs will be needed to improve the system, but we cannot see going back to papers of handwritten notes.

 

[MRG]

Agree for data entry, but for retrieval the doctor will need to search the records in the computer.

IMO a large part of the difficulty is that computer-based records too often lack obvious reference points and cues. When I have a physical folder of papers, after time I develop a "feel" of where individual items are kept because I remember an item's physical location within the folder. On the computer there are fewer visual cues, and zero physical ones.

That was a problem going from paper to electronic records, no coffee stains, or other clues on the most important items.

There's a benefit to all of us. Megacorp sold software into the health care industry before ERM solutions were fully baked. My group went to a hospital where it was being used to manage loose sheets. These were physicians orders that may or may not have been signed, but the patients file couldn't be located. There was a backlog of several hundred thousand square feet of loose pieces of paper. These were your medical records! One thing I know, is when there's that much paper being handled, some of it gets lost.

One of the promises made was the docs could work from home signing off documents.

I watched my long term PCP go from paper to EMR. I think I was in his office the second day he was on a laptop, wow! After we stopped laughing when I told him he looked like a monkey having sex with a bulldog I gave him some pointers. Like getting a mouse! They gave these docs standard laptops with trackballs, nobody over thirty can use one. Yes GUI applications tend to require multiple clicks, power users appreciate hot keys.

I noticed a difference in how my older PCP adapted to ERM opposed to my shiny new PCP who probably never worked on paper.

 

[mexexpat]

I have doctors of all ages. Those 60 years old+ complain about their computer interaction while my 30-something internest never mentions it and is able to make eye contact with me while he types.

 

[Octogirl]

Computer use in PCP

As a NP in primary care, I know there is much more work after an office visit to complete electronic tasks.

Many tasks are frustrating - example- Last week -a patient who was scheduled for flu vaccine -decided to decline- But the order was already entered. No problem - just delete it. My old school method was to cross it out on paper chart- done. Instead, it took my local admin and I about 10 minutes to figure out how to do this.

I know this is a small example, but it magnifies over the course of the day and week. A task that should be simple -is not.

 

[mexexpat]

As a NP in primary care, I know there is much more work after an office visit to complete electronic tasks.

Many tasks are frustrating - example- Last week -a patient who was scheduled for flu vaccine -decided to decline- But the order was already entered. No problem - just delete it. My old school method was to cross it out on paper chart- done. Instead, it took my local admin and I about 10 minutes to figure out how to do this.

I know this is a small example, but it magnifies over the course of the day and week. A task that should be simple -is not.

It's the Learning Curve. Took you 10 minutes the first time; now you know and next time it will take 10 seconds.

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.

 

[MrsHaloFIRE]

On the patient side, I see see the benefits. 6 different duty stations in rapid succession. Major heart surgeries etc. And the vast majority is in the military electronic health record. A doc in tx can quickly scan thru and say oh I see you had an xyz test 3 years ago on your neck in PA. Maybe they caught a good look at your other nearby body part also. Click click. Yes they did! Yes thats arthritis or whatever. Boom. Saved an extra scan, everyone's time etc. This has happened on too many occassions to count. I LOVE it. Although the misc notes section us a riot as "post operative instructions guven to daughter." No children here. I think they mean given to hus wife. Did they test him for some weird bacteria after deployment? (No idea) Why yes they did, that weird bacteria. Who was your doc? (He was cute? No idea on name) Oh Dr what's his face. I know whats his face. He's thorough...etc. Love it.

 

[Bir48die]

This is a subject that has interested me the last couple of years. First thing in every appointment is a sign on and a bunch of typing. Then they ask what my issue is and they type some more. Some will divert their eyes to me and some won't. Then when they've entered in the subject of my visit I finally get the physical assessment. Upon completion we talk about remedy or a conclusion that I'm in incredibly good shape (outside of all my problems) and they type the last bit in. I'm sure one of the medical classes added has been keyboard training

 

[Octogirl]

Yes, but I have been using computer software in my other areas of life for 30 years. Back in the 80's was one of the first to use PC.

I think that is Gawande's point - it is not that he is unfamiliar with computer tech - it is that some of the EMR systems were not built with end users in mind. IMHO

 

[sengsational]

The software needs to catch up to what I have in the living room.....Alexa, excise the blackhead..."ok, exciting the patients head."

 

[GrayHare]

It's the Learning Curve. Took you 10 minutes the first time; now you know and next time it will take 10 seconds.

Provided the UI hasn't changed. UIs took a big hit with small screen devices. Even apps designed for big screens have UIs better suited to smartphones.