Monday, January 04, 2010

An Honest Physician Survey on EHR's

I often believe surveys of physicians about EHR's do not present the results candidly, but rather are selective in what is reported - and what is omitted - and generally sugar-coated. Examples of very candid reports are rare, probably due to pushback, such as this recent report on ED EHR's in New South Wales from Australia.

Often the pushback takes the form of the report "lacking peer review", which in a non-free market, vendor-dominated situation (as in pharma, with money flowing everywhere but up) is as likely to produce censorship or, at best, groupthink, as objective science.

Here is one that is candid, by the American Association of Physicians and Surgeons.

The Association of American Physicians and Surgeons , founded in 1943, regularly testifies before the U.S. Department of Health and Human Services regarding development and implementation of health information technology. It consists largely of physicians in private practice. I've been a member of the organization, but was not at the time this survey was performed and written up:

PHYSICIAN ATTITUDES & ADOPTION OF HEALTH INFORMATION TECHNOLOGY (PDF)

Results Compiled on 6/9/2008

Specialties Responding:

Family Practice 73
Psychology 38
Internal Medicine 33
OBG 27
Orthopedic Surgery 27
Ophthalmology 26
General Surgery 22
Dermatology 21
ENT/OTO 15
AN 14
Neurology 13
Pain Management 13
Urology 12
Pulmonary
Diseases 11
Neurosurgery 8
Vascular Surgery 6
Cardiology 5
Radiology 5
Gastro 5
Emergency Med 4

I am simply reproducing some of the comments received below without additional comment:

A patient's medical history is nobody's business but the doctor's and the patient's.

All EHRs examined are cumbersome and ineffiecient

As a 'computer programmer,' can see pushing buttons to make statements about a patient's health, really makes patient care more distant, takes the personal, hand-touched art out of practicing medicine, AND lends itself to inaccuracies and errors

As a primary care physician, I rarely see patients for one problem, yet most EHRs Ive tested are based on the 'problem/visit' models.Expanding the visit to include the 'oh, by the way, doc's' is cumbersome and even more time consuming.

Better--paper record (for patient, also, to keep)

Big Brother is watching you--1984

Can't view my study printouts and look for change--pages 'turn' too slow

Comment: I do write notes on my computer but it is not part of any 'system.' I do not send bills via computer.

Comment: as anesthesiologists, we use the hospital's EMR, but we haven't implemented our own. Possibility that it won't lead to improvements in quality of care

Comment: However, I work with a physician's group to promote EHRs and run into many obstacles

Comment: we have spent upwards of $200,000 on Nextgen software plus hardware for our clinic and have never been able to make it function over the past 5 years

Compatibility

Concern about presumed access to record by multiple non-insurance third parties.

continued cost of support, maintenance, and updates of hardware and software

cost benefit ratio too high

Cost of upgrades

degradation of personal dr/pt relationship. Instead of a conversation between two people there is the intrusion of a mechanical 'other.'

Distraction from personal patient care

diverts attention from patient to data processing

Doesn't work. Studies show no better. Push for EHR due to 'Big Brother's' appetite for info and control.

Don't need it or want it. Concern about accuracy. Many of the automated consult letters I receive contain glaring errors and omissions.

EHR generates false pre-programmed info that does not truly reflect the time actually spent with the patient allowing the MD to 'upcode' for the visit and bill higher. It is more honest for me t spend 20' with my patient and write wo words of actually pertinent info.

Ehr in use for nurses only at my second site and it slows down the care they give.

EHR is most impersonal. It does not give a fell for what is going on with patient.

EHR notes are poor, very poor. Full of useless verbiage and usually no place for physicians to add specific notes (or they are lost in the mass of irrelevant detail automatically supplied by the program. Also encourages physicians, who are often pressed for time, to make any specific notes.)

EMR are very time consuming, result in production of lengthy repetitive notes of questionable clinical value and reliability.

Comment: companies go out of business and new systems need to be installed.

Comment: Federal and state govt. will continually add requirements

EMR printouts contain extensive boiler plate data. The real data is hard to glean from the chaff.

Fills the chart with negative (non-used) information

Getting the computer 'right' will become more important than taking care of the patient.

Have started process

Have used EHR and find written records more reliable and practical

I am a fulltime ER doctor. I have no say but if they go electronic, I go.

I am blind

I am concerned with control that's being exercised here. There's no room for creativity, judgement and financial shortfalls. If the government or insurance companies would take the overhead including this financial then it might be palatable

I am not a good 'typer'--on a keyboard--I do not type at all. Don't want to type, never will. I am not trained as a secretary or clerk.

I do not want to have to turn on a computer everytime I speak to a patient or need a chart with consulting with another physician or a pharmacist.

I feel like I would be a secretary to enter data on my patients so that government can easily slide into socialized medicine.

I hate typing and anything that distracts me from writing and examining

I have not found a system that will speed up my patient encounter. All make it slower--with keyboard--not patient--time.

I see no benefits; would certainly disrupt my thinking process.

If mandated--no standard for format. Took 15 years to finally get standard for electronic billing.

If purchased would be faced with frequent expensive changes to format. They still can't get the new NPI number to work! Everyone I know who spent $50,000 to buy a system either junked it or are planning to!

In 2000, I lost my billing staff. Led to a computer-based billing system due to that. The transition was horrible! I could not use the system myself and training for staff was expensive; the IT guy was expensive; billing personnel who had experience with my system were few. In the end, 4 years later, I had an AR $136,000 and as aconsequence, I closed that practice

Inappropriate EMR causes defocus from reason for visit, etc. Problem with sketches.

Still would need 2 charts--one paper, photos, etc. and 1 EMR

Inefficient. They do not provide the clinical data that I need.

It is impossible to skim through an electronic record to find data. It is impossible to sketch the affected anatomy in electronic records. If the computer breaks down or the technology becomes obsolete, the patient record disappears. It takes too long to enter data into a computer.

You still need a paper chart to share reports and other patient paper records.

It will be of no value in my single practitioner spine surgery practice lack of any standard format/compatibility of various systems

Lack of personal patient interplay

Less time with patient, more time with computer. There are better ways to give ER docs access to patient's med records. Survey ER docs to learn what info they would need when pt. is unconscious. Put that into pt. ID card using 2D Barcodes or magnetic strips. Card readers in ERs can then access that info. If AAPS helped develop and sponsor this for its members, it could be a source of $$ for AAPS

loss of dr-patient relationship

Loss of patient control over privacy of records

Loss of quality of patient's personal records. Physical deterioration of data over many years

Inadequate accuracy of voice recognition technology Lack of evidence that EHRs
are any better or equal to paper records except in narrow applications

I purchased an EHR system and was unimpressed. Main reason: prefer personal notes. I believe dictated notes are more specific and detailed and are customized for each patient visit

May not be able to get to computer records in case of computer crash or power failure (eg. Katrina).

most software have major problems in functionality and changes how physicians practice in a potentially negative way

Must have voice recognition for input at 100% accuracy and reliability.

my patients are given copies of all reports (lab, x-ray, consults) as they are collected and told to keep in their medical file

No adequate voice recognition systems

No clinical evidence that this improves outcome. No clinical evidence that there is a return of investment.

No evidence that EHR will improve care or reduce costs to the patient/doctor/healthcare system.

No improvement in quality of care provided.

Once they force us into the more expensive, time-consuming system that does not work, they
own us! It is too easy for the courts, government, hackers and insurance companies to take 'all,' once it is in the system!

One of worst business decision we made.

open source software is available (but VA Vista split into Open Vista and World Vista groups and is written in a language that is not known to many programmers) but I haven't taken the time to find something that could work--I don't know if any of them can keep up with the government requirement

oppose all government interference

Paper charts are much more accurate and efficient for me.

Patient safety

perpetuation of errors

Preoccupation with the computer takes time from patient. Increased errors from EMR especially CPOE. We already have well established safety checks and reviews in our system for tracking tests and medicines. No system especially CPOE have been tested for safety and efficacy nor approved by any regulatory agency and thus the alteration of care from these (?) is nothing but an experiment and patients have not signed consent. Preoccupation with the computer takes time from patient. Increased errors from EMR. We already have well-established safety checks in our system for tracking tests and medicines. No systems have been tested for safety and efficicacy nor approved by any regulatory agency

Reduced time with patients. My patients complain about other doctors playing with EHR computer instead of looking at them during visit.

reliance on psychological pen and paper tests

Slower system than handwritten notes

slows review of chart at each office visit

some parties are paying $10,000 per month for technical support

Sorry, I cannot fill this out--I have visual problems

Still building the software

Studies are not showing conclusive evidence that EMRs improve patient care or safety, but do increase practice costs.

systems are difficult to implement; I've been trying for 2 years

The EHR in the hospital slows me down. A paper record is more efficient for me.

The systems seem to impede quality clinical care and passing along of relevant clinical information

There is not one advantage to me, at all!

There is one product I would use, PRAXIS. [www.informed.com] I would need $30,000 infrastructure and $30,000 adoption overhead grant in order to do so

They don't improve patient care--just adds to overload

time taken up up for data; focus on computer rather than on patient in the exam room

Too rigid. I like to draw pictures of what I see on ophthalmological exam.

Typed, dictated note can be read much more quickly. I use a print about 1/2 the size of your print on this page and there are perhaps 4 or 5 pages of regular print per page which I read without glasses. Computer and power problems do not hide my records.

Unfunded mandate with huge cost in a severely declining reimbursement arena.

without a personalized note, it is worthless.

Read the entire report as linked above. No additional comments are needed.

-- SS

38 comments:

IT Guy said...

It's the March of the Ludites.

Thanks for a very funny post.

MedInformaticsMD said...

As we say so often on Healthcare Renewal about argumentum ad hominem, the label "Luddite" is ad hominem. It does not address any of the issues raised by practicing physicians.

About "thanks for a very funny post", see my recent post "Are Dissmissive Industry and Government Reactions to Physician Concerns about EHR's and other Clinical IT Simply Perverse?"

-- SS

Anonymous said...

From Wikipedia re this org that you now belong to and who published the survey:

"The Association of American Physicians and Surgeons (AAPS) is a politically conservative non-profit organization founded in 1943.[1] The group had approximately 4,000 members in 2005."

Their politics may be mainstream (ie representative of most docs) but a fairly small group wouldn't you say

-- a liberal believer in some sort of EMR, some day

IT Guy said...

No one is dissmissive of legitimate concerns. Luddites are a different story. Most of the "concerns" in that diatribe are of the Luddite variety.

MedInformaticsMD said...

IT Guy writes:

"No one is dissmissive of legitimate concerns."

I see. You decide what's legitimate.

Maybe EHRs Do Involve Training Extremely Competent Humans.

-- SS

IT Guy said...

You decide what's legitimate.

No. We work with our customers. Hopefully we won't be working with the doc who said "There is not one advantage to me at all." I doubt we'd get any useful insight from that one.

MedInformaticsMD said...

Anonymous wrote:

Their politics may be mainstream (ie representative of most docs) but a fairly small group wouldn't you say

So what? They are another added data point to an accumulating body of evidence that HIT in its present form has been vastly oversold.

Unless you mean that because they're jack-booted right wing, teaparty-going extremists who answer to Karl Rove, their opinions cannot be valid or representative of physicians at large.

-- SS

IT Guy said...

without a personalized note, it is worthless.

This is another favorite of mine. Do you have any idea what kind of "personalized note" this doc is talking about?

IT Guy said...

I am not a good 'typer'--on a keyboard--I do not type at all. Don't want to type, never will. I am not trained as a secretary or clerk.

This is another interesting one. This doc made it through med school, but is overwhelmed by poor typing skills?

IT Guy said...

Too rigid. I like to draw pictures of what I see on ophthalmological exam.

What if the system allows you to take a photo and attach the photo to the patient record? Is that still "too rigid"? Do you think your drawing would be better than an actual photo?

I could go on and on. Most of these people are just looking for excuses to keep their buggy whips.

Roy M. Poses MD said...

In what other field would numerous complaints about the difficulties use of a product entails be dismissed as coming from backwards and ignorant consumers, rather than cues to revise the product design?

IT Guy said...

In what other field would numerous complaints about the difficulties use of a product entails be dismissed as coming from backwards and ignorant consumers

I'm pretty sure the auto industry probably ignored virtually every complaint made by people who wanted to keep their buggy whips.

In any case, I picked 3 specific responses. You were unable to refute anything I said.

IT Guy said...

rather than cues to revise the product design?

Did you miss my post about adding photographs to the system (which probably isn't really a revision, it's probably a feature of many systems)?

Roy M. Poses MD said...

IT Guy, I was going to leave it to MedInformaticsMD to reply, and you may be surprised, but I have things to do other than to provide you with instant responses, but if you insist -

"a personalized note" likely means an opportunity to provide a free text response in addition to or instead of checking off boxes.

"not a good 'typer'" - It may be a surprise to you, but many excellent physicians, especially older ones, may not know how to type. Physicians who are not forced to use EMRs may never need to type to be excellent practitioners. Why should they use their valuable time to learn how to type?

"draw pictures" It may not be very easy to take photographs of what is of interest. Standard instruments used in the eye exam may not readily couple to cameras. On the other hand, how difficult would it be to provide software that allows simple free-hand drawing?

They all seem like reasonable survey responses to me.

In response to your buggy whip comment, we are talking about a profession that deals with life and death issues. If a physician says an interface is hard to use, or a system's ergonomics are bad, you want to tell him or her to just suck it up, in the hopes that the results do not hurt patients? Are you going to be accountable if patients are hurt?

Finally, IT Guy, I no longer see the point in your continuing anonymity. Your defense of the status quo in the health care IT industry hardly makes you a whistle-blower. Would you care to reveal who you are?

IT Guy said...

without a personalized note, it is worthless.

By the way, this complaint is similar to someone going to the ER and saying "I am sick." It may be a legitimate problem, but without any context it is completely useless.

IT Guy said...

In fact, I do.

If you know, why did you put so much effort into puffing up your chest and no effort into saying what it is?

I know what a personalized response is. That isn't the problem. The problem is where in the system does tbis person want a personalized response. There could be any one of hundreds of places where we are looking for user input. Which place is this user complaining about?

I know quite a bit more than you about medicine and healthcare computing.


You know more about healthcare. If you think that this list of survey responses is useful in any way, you know next to nothing about healthcare computing.

As I stated above, that complaint (and most of the others, as well) is the equivalent to walking into the ER and telling the ER doc that you are sick. It may be a problem, but the info you have provided is useless.

IT Guy said...

the broad based clinical and scientific training physicians undergo in medical school as referenced in the document above

Except learning to type, apparently.

MedInformaticsMD said...

IT Guy wrote,

"This is another favorite of mine. Do you have any idea what kind of "personalized note" this doc is talking about?"

In fact, I do. Both from personal experience writing thousands of them in practice, and from studying medical language systems - e.g., controlled terminologies, ontologies, complex and subtle lexical and semantic issues in translating clinical and social observations and findings into computable data, issues related to biomedical knowledge capture, etc. at Yale School of Medicine as a post doctoral fellow and then research scientist in Medical Informatics.

I'll go further. In addition to years of work as a Medical Informatics Director in a large hospital, work in knowledge management in Big Pharma, private and corporate occupational practice of medicine, three years of internal medicine residency and a year of diagnostic imaging, three years of premed courses focusing on biomedical sciences (my BA is in that field), four years of medical courses and clinical rotations as outlined in this document, and several summers spent with medical and surgical teams as a high school student, I know quite a bit more than you about medicine and healthcare computing.

Why don't you list your corresponding credentials that could justify your beliefs and opinions on clinical affairs?

In fact it seems to me that only a lack of medical education and experience could cause a person to even raise such a question about physician documentation.

I believe most laypeople -- including the management class -- have little idea of the broad based clinical and scientific training physicians undergo in medical school as referenced in the document above, hence their belief they can render reasonable judgments in the domain.

They certainly have little clue what Medical Informatics postdoctoral fellows study, either.

IT Guy said...

They certainly have little clue what Medical Informatics postdoctoral fellows study, either.

Let's put that education to work.

You are a HIT programmer and a physician complains to you "without a personalized note, it is worthless."

What is your response?

Anonymous said...

Dear IT Guy,

I am not sure I understand why you are so upset. Splain yourself. So what, SS has taken the veneer off the charade. There are still many dollars to be had.

From a fellow HIT innovator

IT Guy said...

I am not sure I understand why you are so upset.

I don't like grandstanding self-promoters.

SS has taken the veneer off the charade

He has done nothing of the sort.

Roy M. Poses MD said...

IT Guy, or whoever you are -

You seem to misunderstand the point of the survey that MedInformaticsMD cited above. It seemed to be a general survey about health care IT. It did not seem to ask for detailed responses about specific problems with specific health IT systems.

By the way, you still are ignoring my previous question about your identity. Since you seem to be a vigorous defender of the status quo, you obviously should not fear retaliation for being a whistle-blower by industry. So why do you continue to be anonymous?

Roy M. Poses MD said...

IT Guy -

You are descending to the ad hominem, while failing to add any intellectual content, and still remain anonymous.

You seem to be unable to provide further substantive responses.

Because you insist on remain anonymous, but seem unable to provide substantive responses, I wonder if the motivation for your anonymity includes that you have financial self-interest in defending the status quo, and do not want to reveal what that self-interest is?

Further ad hominem comments will be rejected.

IT Guy said...

It did not seem to ask for detailed responses about specific problems with specific health IT systems.


Then why did SS post that list of responses as if they were significant?

IT Guy said...

You are descending to the ad hominem

You need to look up the definition of ad hominem. I'm doing nothing of the sort.

IT Guy said...

You seem to be unable to provide further substantive responses.


I provided substantive responses to 3 examples of survey responses. I provided substantive responses to your attempt to refute me. At this point you still haven't explained why you think "I can't type" is a legitimate excuse for someone who managed to survive med school. If there is anyone here who has shifted from substance to ad hominems, it is you.

IT Guy said...

defending the status quo

What "status quo" are you talking about? There is no such thing as a status quo. We are constantly updating these systems.

MedInformaticsMD said...

IT guy:

Recently noted this in the logs with an outclick to your comment at https://www.blogger.com/comment.g?blogID=9551150&postID=4799128165855153590&isPopup=true :


Domain Name (Unknown)
IP Address 12.11.157.# (Medical Information Technology)
ISP AT&T WorldNet Services
Location
Continent : North America
Country : United States (Facts)
State : Massachusetts
City : Milford
Lat/Long : 42.1544, -71.521 (Map)
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Browser Internet Explorer 6.0
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Visitor's Time Jan 4 2010 11:49:49 am
Visit Number 643,748

You wouldn't happen to work at Meditech, would you?

If so, do you think employees or executives at HIT vendors have better things to do then spend 1 hour 5 minutes 23 seconds reading 12 posts at blogs?

MedInformaticsMD said...

IT guy wrote:

"I don't like grandstanding self-promoters."

In fact, it seems what you don't like are independently-thinking physicians.

MedInformaticsMD said...

There it is again: Meditech, outclick to this comment thread at about the time IT Guy posted.


Domain Name (Unknown)
IP Address 12.11.157.# (Medical Information Technology)
ISP AT&T WorldNet Services
Location
Continent : North America
Country : United States (Facts)
State : Massachusetts
City : Milford
Lat/Long : 42.1544, -71.521 (Map)
Language English (U.S.)
en-us
Operating System Microsoft WinXP
Browser Internet Explorer 6.0
Mozilla/4.0 (compatible; MSIE 6.0; Windows NT 5.1; SV1; .NET CLR 1.1.4322; .NET CLR 2.0.50727; .NET CLR 3.0.04506.30; .NET CLR 3.0.04506.648)
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Visit Exit Page http://hcrenewal.blogspot.com/
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Time Zone UTC-5:00
Visitor's Time Jan 5 2010 9:38:07 am
Visit Number 644,308

Roy M. Poses MD said...

IT Guy -

Calling MedInformaticsMD a "grandstanding self-promoter" was ad hominem.

Your last substantive comment was the one at 6:33 PM on 4 January.

The survey that MedInformaticsMD originally posted about was obviously not designed to provide specific feedback about particular systems to inform their modification. The survey was meant to get more general responses from a population of physicians who used multiple systems. Castigating a responder to the survey because he/she did not provide a detailed enough comment to inform system design makes no sense.

By "status quo" I meant the general approach to the design of EMRs and health care IT that seems to be employed by many commercial vendors, an approach that uses little input from users, and little uses from informed physicians including medical informatics specialists.

See all my above comments.

IT Guy said...

an approach that uses little input from users, and little uses from informed physicians including medical informatics specialists

That isn't the status quo. Every change we make includes input from our users.

MedInformaticsMD said...

IT Guy wrote:

"Every change we make includes input from our users."

You've already demonstrated a severe attitude problem with regard to physicians, though - in fact, contempt.

e.g., your perverse statement about the AAPS physician comments on HIT difficulties being "funny", followed up by the equally perverse comment that:

"No one is dissmissive of legitimate concerns. Luddites are a different story. Most of the "concerns" in that diatribe are of the Luddite variety"

-- as if you or your company alone decides what concerns are legitmate, and which are of "the Luddite variety."

How can any physician or healthcare organization do business with HIT companies whose progammers and executives exhibit such a culture?

IT Guy said...

You've already demonstrated a severe attitude problem with regard to physicians, though - in fact, contempt.

That simply is not true. I have demonstrated contempt for you, not all physicians.

Anonymous said...

In reading this thread of comments I have to believe IT Guy is a salesperson. My only question is: Were you assigned this blog or did you choose it? We had this problem a number of years ago where a salesperson was assigned a number of blogs with the intent of using up valuable time in trying to discredit the postings.

In my very first sales class we learned to focus on irrelevant points, constantly shift the discussion, and generally try to distract criticism. I would say that HCR is creating heat for IT Guy’s employer and the industry in general.

I find it sad that a company would allow an employee to attack anyone in an open forum. IT Guy needs to check with his superiors to find out if they approve of this use of his time, and I hope he is not using a company computer, unless once again this attack is company sanctioned.

Steve Lucas MBA

MedInformaticsMD said...

IT guy writes:

"That simply is not true. I have demonstrated contempt for you, not all physicians."

I'm sorry, it's clear your physician contempt is quite generalized. For example, the AAPS physicians whose concerns you found "funny" and "Luddite."

MedInformaticsMD said...

In my very first sales class we learned to focus on irrelevant points, constantly shift the discussion, and generally try to distract criticism.

Steve,

I did not know such skills were actually taught.

To the majority of readers of this blog, focusing on irrelevancies, constantly shifting the discussion, and generally trying to distract criticism are signs of hysteria or stupidity. As physicians, we've seen all kinds.

Here, commenters who resort to those tactics have nothing to sell.

-- SS

pengobatan said...

From Wikipedia re this org that you now belong to and who published the survey: "The Association of American Physicians and Surgeons (AAPS) is a politically conservative non-profit organization founded in 1943.[1] The group had approximately 4,000 members in 2005." Their politics may be mainstream (ie representative of most docs) but a fairly small group wouldn't you say -- a liberal believer in some sort of EMR, some day.

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