Sunday, April 27, 2008

On the Pitfalls of Going Electronic: Should Physicians Reject Hospital EMRs?

Yes, I believe they should, and with a spine, especially when they're lousy and their design and implementation have been led by people with superficial "certification" and/or no clinical credentials whatsoever. And sometimes no discernible IT credentials, either, unless you consider the "school of hard knocks" a credential.

(More on the credentials issue below. Also see my website "Common Examples of Healthcare IT Difficulties" for more on these issues.)

A viewpoint article was just published in the NEJM by Harvard physicians Pamela Hartzband, M.D. and Jerome Groopman, M.D. entitled "Off the Record — Avoiding the Pitfalls of Going Electronic" (NEJM 358:1656-1658, April 17, 2008).

The authors note:

... The ultimate goal of the electronic medical record — a technological solution being championed by the Bush administration, the presidential candidates, and New York Mayor Michael Bloomberg, as well as Google, Microsoft, and many insurance companies — is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. The history, physical exam findings, medications, laboratory
results, and all physicians' opinions will be collected in one place and available at a single keystroke. And there is no doubt that these records offer many benefits. We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides.

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.

Residents, rushing to complete numerous tasks for large numbers of patients, have sometimes pasted in the medical history and the history of the present illness from someone else's note even before the patient arrives at the clinic. Efficient? Yes. Useful? No. This capacity to manipulate the electronic record makes it far too easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong. Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family history, social history, and review of systems. Though it may be appropriate to repeat certain information, often the primary motivation for such blanket copying is to pass scrutiny for billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.

In effect, the doctors have keenly observed that not only do EMR's impair documentation and thinking by seasoned professionals, especially those pressed for time, but the use of these technologies impairs the training of the next generation of physicians. I benefited much through learning how to properly document medical observations, findings, differential diagnoses, treatment plans, and other high level cognitive processes. IT designed by non clinicians with the maintenance of payor profit as a principal motivator may be, in effect, causing a further dilution in the quality of medical training. Social informatics predicts such unexpected adverse outcomes of any new information and communications technology (ICT).

However, the current environment of irrational exuberance over Health IT, as well as the potential for capital transfer from the healthcare to the IT and payer sectors and the motivators and conflicts this generates among hospital management, consultants, regulators and others, has had a marked blinding effect.

The NEJM authors also note:

Similarly, electronic medical records can reproduce all of a patient's laboratory results, often dropping them in automatically. There is no selectivity, because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems. Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

...The worst kind of electronic medical record requires filling in boxes with little room for free text. Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue. Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs.

... These problems, we believe, will only worsen, for even as we are pressed to see more patients per hour and to work with greater "efficiency," we must respond to demands for detailed documentation to justify our billing and protect ourselves from lawsuits. Though the electronic medical record serves these exigencies, it simultaneously risks compromising care by fostering a generic approach to diagnosis and treatment.


I agree with these assessments, especially for hospital based enterprise EMR's forced on doctors by management.

Physician leadership of HIT projects would be of great benefit. However, here's what typical healthcare organizational leaders have to say about physician leadership of HIT initiatives, in this case Denis Baker, the CIO of Sarasota Memorial Hospital, a major medical center on the Gulf Coast of Florida in an interview here:


I think that physicians bring a certain aspect to the job, but I don’t think they necessarily know how a hospital works. I think they know how their practice works and how they interact with the hospital, but I don’t think they absolutely know what nursing does, or any of the ancillary departments, and what they do.

Worse, as far as I can tell, the CIO making that statement appears to lack formal education in medicine, information systems, information technology and biomedical information science i.e., informatics. (I was unable to find any such credentials but will correct this if mistaken.)

Stereotypes of physicians do not come any more patronizing than that.

Oh, wait ... yes they do.

His statement is little different than a decade ago when I wrote this essay about stereotypes and observed others in influential positions holding marginalizing views of physicians - and indeed of professional education of any kind:
Several healthcare MIS Recruitment firms have published interesting views on healthcare MIS leadership, views that most clinicians will not identify with. " I don't think a degree gets you anything ," says healthcare recruiter Lion Goodman, president of the Goodman Group in San Rafael, California about CIO's and other healthcare MIS staffers.

Healthcare MIS recruiter Betsy Hersher of
Hersher Associates , Northbrook, Illinois, agreed, stating " There's nothing like the school of Hard Knocks ." (Who's Growing CIO's, Healthcare Informatics, Nov. 1998, p. 88).

In seeking out CIO talent, recruiter Lion Goodman " doesn't think clinical experience yields [hospital] IT people who have broad enough perspective . Physicians in particular make poor choices for CIOs. They don't think of the business issues at hand because they're consumed with patient care issues ," according to Goodman.

It appears there's been little change in ten years.

Oh, wait ... yes there has been "change."

"Specialists" and "managers" in HIT projects now undergo certification by vendor-centric groups such as the Health Information Management Systems Society HIMSS.

Here's a description of the value of certication as a HIMSS Certified Professional in Healthcare Information and Management Systems (CPHIMS):

CPHIMS status provides both internal and external rewards. As a Certified Professional in Healthcare Information and Management Systems, you:

  • Distinguish yourself from your peers as certified in healthcare information and management systems;
  • Expand your career opportunities;
  • Signal that you have mastered proven, broad-based concepts through successful completion of the Certified Professional in Healthcare Information and Management Systems Examination;
  • Provide yourself with skills and tools to help you make a difference in your career, your organization, and your community;
  • Enjoy the pride of recognition of knowing that you are among the elite in a critical field of healthcare; and
  • Have a premier credential based on a sound assessment to distinguish yourself in an increasingly competitive marketplace.

Wow! "You are among the elite" after taking this exam!

Here are the eligibility standards:

Baccalaureate degree plus five (5) years of associated information and management systems experience*, three (3) of those years in healthcare.

Graduate degree plus three (3) years of associated information and management systems experience*, two (2) of those years in healthcare.

*Associated information and management systems experience includes experience in the following functional areas: administration/management, clinical information systems, e-health, information systems, or management engineering.

And now, the certification instrument:

The CPHIMS credential is awarded to individuals who demonstrate eligibility for the Certification Program and who successfully complete a qualifying examination. The examination consists of 115 multiple-choice test items, presented during a 2-hour session. Scoring is based on 100 items pre-selected for desirable psychometric characteristics. The additional 15 test items are included as pretest items. Performance on pretest items does not affect a candidate’s score.

That is the certification that will be used to hire more "experts" in HIT.

This is pathetic. My exams to become a licensed ham radio operator were more challenging. I consider such a credential unmeritorious at best, fraudulent at worst. (I haven't even inquired as to costs.)

However, medical credentialing exams are just a bit more thorough.

By several orders of magnitude, that is.

In conclusion, medicine is in very sad shape when in an era of out of control technology costs ($100 million for an EMR?), unclear benefit and irrational exuberance over HIT it's demanded of physicians that they use tools designed by business IT personnel, processes and methodologies best known for failure, produced by an industry rife with conflicts, whose leaders often lack substantive credentials, patronize those who do, produce ill-conceived and/or shoddy products whose use is mandated by non-clinician hospital managers and that as the NEJM writers note, impair medical practice and education.

-- SS

8 comments:

Anonymous said...

While I must say that I agree with the fact that the "templates" in EMRs could be a huge problem, I must enfore the words "could be". I personally hate templates as they are far from what seeing a patient is all about.
Templates are in EMRs for ease of use for the MD's patients that generally meet the general template. This does not mean that the template and only the template should be used. There is no person that fits a template to a "T".
I am sorry but I must put at least 50% of the blame on the physicians here. MDs need to take the time to alter the template to fit their patient issues, needs, etc. Cutting and pasting is the lazy man's way out and completely wrong at that. There is no way that an MD can provide the best service for their patients if they cannot take the time to create some customized sentances here and there.
For Gosh sakes, most physicians used to handwrite the entire note so how long can it really take to add a few sentances here and there to a template?
Also, most larger facilities such as hospitals are still dictating instead of using the full EMR template so for this instance, there is really no reason for the lack of customization of charts to their patients.
I have worked in the medical field for several years and I know that MD's time is precious but there needs to be adherence to the most excellant medical care as well.

Anonymous said...

I am only a first-year medical student, but I have already seen first-hand some of the problems associated with EHRs. The one we use for "training" is cumbersome, hard to navigate and tedious. It is painfully clear that it was designed by someone who had never taken an H&P or written a SOAP note. It takes forever to complete - much, much longer than a hand-written note - and there are discrete, pre-programmed categories for the history components. A family history of thyroid disease, for example, can go in "family history," "family cancer history," "family endocrine history," and so on. So where should it go? In one or all three? Put it in one and risk it not being noticed? Or put it in all three and have multiple duplications of the same information, which took extra time to complete? Plus, good luck finding lab results or imaging studies. They are buried in a morass of interminable, counter-intuitive menus. On top of that, our training EHR is not even the same system that is used by the university hospital! Yes, EHRs are definitely the answer to our health-care crisis, if you have Cerner stock.

Ian Furst http://www.waittimes.blogspot.com said...

Fantastic post -- I've been arguing this point forever and it's been slow going. For ANY project to work it has to increase quality and efficiency. If it only does one or the other it's an uphill battle. For 99% of patient EMR is only a modest gain in quality (and some would argue that) but it can be an efficiency killer if done poorly. Part of the problem is programming but our major hurdle was a bad network. Constant login/logout, lost printers, blah, blah, blah. If google had put their minds to efficiency instead of portability they'd be in a very different place right now with their health care application.

Great post and good links. Thanks for pointing it out.

MedInformaticsMD said...

If you read some of my stories at my website on HIT difficulty here, you'll note several stories where the incompetence and arrogance of so-called "IT professionals" likely could have been harming patients. The first two cases on that site are mine personally, and from a major regional healthcare system.

These IT personnel were never held accountable, and in fact have moved on to inflict their views (they believe they are the "enablers" of healthcare via the brilliance bestowed on them by their bachelor's degrees) on other healthcare systems.

When you encounter an EMR, CPOE or other clinical IT that's crap, my advice is to respond to its infliction upon you as you would, say, a bottle of VIOXX or a tainted vial of heparin someone was trying to force you to use.

Tim said...

It's very good that these more realistic assessments of EMR's are finally coming out - it could slow the adoption of these monstrosities that contribute very little to patient care and, in fact, consume a lot of time in data entry.

It seems to me that the real force driving EMR is the desire to facilitate further fragmentation of care by increasing the number of caregivers and their turnover. This, in turn, is being driven by deteriorating working conditions in the healthcare industry and even among doctors who are not willing to work the hours they once did. So the idea is that EMR will allow downloading of a lot of info quickly into the next professional's head with frequent change-offs, change of shifts, etc.

I think it will eventually be found that it is more efficient, cost-effective, and affords a better quality of care to have fewer caregivers who change off less frequently. But to return to that way of doing things will also require a return to people having personal physicians over extended periods of time and better working conditions for ancillary personnel. This, obviously, is not facilitated by the usual business cost-slashing practices, people changing insurance/HMO coverage frequently for the sake of saving a few dollars and forcing physicians to play games with insurers that have them spending $100 to collect $60 office charges.

In short, the drive for EMR's is occasioned by a need to overcome the problems created by trying to industrialize medical care and make the provision of healthcare into "profit centers." I think it will be a very imperfect fix and create many new problems, as it is already doing.

MedInformaticsMD said...

In short, the drive for EMR's is occasioned by a need to overcome the problems created by trying to industrialize medical care and make the provision of healthcare into "profit centers." I think it will be a very imperfect fix and create many new problems, as it is already doing.

Brilliant. I have often thought complex EMR's such as are being forced on clinicians today (as opposed to the experimental systems of medical informatics' formative years) are massive overkill, and would be largely unnecessary if clinicians were not burdened with megatons of bureaucracy - and had the appropriate levels of ancillary support.

However, ancillary support costs money, and we can't have that.

Better to spend $100 million+ and annual recurring costs on an EMR so we can lay off all those ancillary folks and hire IT people instead, and make clinicians waste time recording everything to fine granular levels of detail, just to make sure the payers get every penny they've so rightly earned through their B-school schemes.

Mark Harvey said...

Quite an interesting post. If awards (or certifications) existed for hubris and paranoia, the author would certainly qualify.

Regarding the EMR:

The authors of the NEJM article are said to “have keenly observed that not only do EMR's impair documentation and thinking by seasoned professionals, especially those pressed for time, but the use of these technologies impairs the training of the next generation of physicians.” (Emphasis mine.)

In fact, the authors are quoted as stating “we've noticed several serious problems with the way in which notes and letters are crafted.”

Who are the “crafters” of the notes and letters in question? Oh, right, it is those “seasoned professionals” who have had their thinking impaired by the insidious EMR.

Sloppy documentation has been endemic with clinicians since Hippocrates was scrawling notes on papyrus. I wouldn’t disagree that automated tools make it much quicker and easier to produce sloppy documentation in even larger volumes, however the responsibility for that documentation rests upon the professional who is crafting it.

I may have been tempted to blame my hammer the last time I missed the nail head and left an ugly mark on the wood. The truth is that the problem was the “user”, not the tool.

Improving the delivery of care is the responsibility of all of us who work in the field. We would do well to cultivate working relationships based on mutual respect and an understanding of what each contributor has to offer. Finger pointing and blame shifting is unproductive.

Let's use that creativity to improve the systems. (Provided, of course, that they haven't already "impaired our thinking" beyond repair.)

MedInformaticsMD said...

Mark Harvey wrote:

Quite an interesting post. If awards (or certifications) existed for hubris and paranoia, the author would certainly qualify.

I first note how this comment begins with an ad hominem attack. Ad hominem is often a principal means of argumentation by those who lack substantive argument.

-------------------------------
From the Nizkor project page on logical fallacy, required reading for my graduate students in healthcare informatics:

Translated from Latin to English, "Ad Hominem" means "against the man" or "against the person."

An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument. Typically, this fallacy involves two steps. First, an attack against the character of person making the claim, her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim). Second, this attack is taken to be evidence against the claim or argument the person in question is making (or presenting). This type of "argument" has the following form:

1. Person A makes claim X.
2. Person B makes an attack on person A.
3. Therefore A's claim is false.

The reason why an Ad Hominem (of any kind) is a fallacy is that the character, circumstances, or actions of a person do not (in most cases) have a bearing on the truth or falsity of the claim being made (or the quality of the argument being made).

-------------------------------

That being said, why might a person resort to such tactics? Perhaps the posting personally touches a nerve. A google search on "Mark Harvey EMR" provides this possible identity:

J. Mark Harvey MS, CPHIMS
Chief Information Officer
Holzer Clinic

I was critiqued for stating that the authors of the NEJM article “have keenly observed that not only do EMR's impair documentation and thinking by seasoned professionals, especially those pressed for time, but the use of these technologies impairs the training of the next generation of physicians.”

From that NEJM article:

... Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking...we have observed the electronic medical record become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.

That strikes me as consistent with "impairing documentation and thinking by seasoned professionals." (also see point below on HCI)

The NEJM article also states:

This capacity to manipulate the electronic record makes it far too easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong.

That strikes me as consistent with "impairing the training of the next generation of physicians", something I perhaps can have an informed attitude about, having gone through that training and now being an educator in the field.

Mr. Harvey also wrote, in blame-the-customer style:

Who are the “crafters” of the notes and letters in question? Oh, right, it is those “seasoned professionals” who have had their thinking impaired by the insidious EMR...the responsibility for that documentation rests upon the professional who is crafting it.

Speaking of hubris, imagine if physicians blamed IT personnel for bad patient outcomes...

I would ask if Mr. Harvey is familiar with the large body of research in human-computer interaction and resilience engineering. It informs that bad design indeed can and does impair even the most skilled of users.

Typically, users often develop shortcuts and workarounds so that they can perform the most critical tasks, which in medicine happens to be patient care, not futzing around with a badly-designed EMR.

Which is it? Good notes and less time for patient examination and interaction? Or workarounds to uninspired HIT design, resulting in lousy notes and better actual care?

In a demanding clinical environment where clinicians are quite busy performing patient care, especially in subspecialty areas, the tools must be the best they can be. Current clinical IT falls far short of this.

Mandated use of EMR's while physicians are also under increasing pressures to "do more with less" is also responsible, and this is a systemic problem.

That said, it's not up to clinicians to be the servant of bad IT, it's the duty of the IT designers to serve the needs of medicine.

It's all about patient care.

One of the reasons I am so insistent HIT leaders have a clinical background is due to this latter observation.

The NEJM authors also observed:

The worst kind of electronic medical record requires filling in boxes with little room for free text. Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue. Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs. One pediatrician told us that after electronically verifying use of seat belts, bicycle helmets, and other preventive measures, she has scant time to explore clinical issues. Electronic medical records may help to track outcomes and adherence to guidelines, but they may also force doctors to give "standard" rather than "customized" care.

Who, exactly, designs such a system? What is their knowledge of medical informatics, social informatics, HCI, clinical medicine, clinical documentation, and other fields?

COuld it be the same people who've designed, as Joan Ash at OHSU observed, CPOE systems that cause cognitive overload because they're "designed for calm and solitary office environments?" Or as sociologist Ross Koppel at Penn observed, that facilitates medication errors risks?

Could it be the same people responsible for the issues that Richard Granger, former head of the UK's “Connecting for Health” national clinical IT program, reported as follow? ... "Sometimes we put in stuff that I'm just ashamed of ... Some of the stuff that [our large American clinical IT vendor] has put in recently is appalling ... [vendor] and [prime contractor] had not listened to end users ... Failed marriages and co-dependency with subcontractors ... A string of problems ranging from missing appointment records, to inability to report on wait times ... Almost a dozen cancelled go-live dates ... Stupid or evil people ... Stockholm syndrome -identifying with suppliers' interests rather than your own ... A little coterie of people out there who are "alleged experts" who were dismissed for reasons of non-performance."

Could it be the folks responsible for bad informatics that kills?

Finally, Mr. Harvey wrote:

Improving the delivery of care is the responsibility of all of us who work in the field. We would do well to cultivate working relationships based on mutual respect and an understanding of what each contributor has to offer. Finger pointing and blame shifting is unproductive.

Scratching my head on this one. It would seem to me Mr. Harvey is attempting to "shift blame" for EMR problems to clinicians...

That said, is finger pointing 'always' unproductive, I ask? I don't think so. I respectfully disagree on this "one shoe fits all" ideology. Warm, fuzzy notions of 'mutual respect' when it is not earned is not a high-ranking priority when non-clinician interference in medical care is harming patients, as in this example. Nobody has ever satisfactorily explained to me how or why I was supposed to show "mutual respect" when helpless, seriously ill ICU patients were put in significant danger through the misapplication of business computing methodologies in a clinical environment, a problem that remains as a root cause of HIT difficulties internationally.

Perhaps some good old-fashioned medical rigor, where the person who's just nearly killed the patient is held accountable in no polite terms, is preferable over "mutual respect."

Mutual respect must be earned, and based on its well-documented track record (see multiple links in my web site on HIT difficulty), the IT world largely hasn't yet earned it in HIT.