Sunday, August 07, 2011

Why EHR's Are Mission Hostile

From "Revisiting E&M Visit Guidelines — A Missing Piece of Payment Reform" (free PDF as of this writing), Robert A. Berenson, M.D., Peter Basch, M.D, and Amanda Sussex, M.P.H., N Engl J Med 364;20 May 19, 2011.


... Numerous problems have resulted. [From the CPT codes, Current Procedural Terminology codes used by physicians in billing, covering evaluation and management (E&M) services - ed.] The detailed guidelines often cause clinicians to overdocument, making the medical record an ineffective source of communication.

... A fundamental concern is that the office-visit descriptors and interpretive guidelines emphasize often-irrelevant elements of patients’ clinical histories and examinations, rather than decisionmaking and care-management activities. This is particularly problematic in the case of clinicians caring for patients with multiple chronic conditions.

Now EHR experts argue that the priority placed on documentation has diverted software designers’ focus from more important activities that would improve the quality and efficiency of care. [3] The current focus produces EHR-generated data dumps, including repetitive documentation of elements of patients’ histories and physical examinations, that merely result in electronic versions of clinically cumbersome, uninformative patient records. [4]

Then why are they popular? Here's why:

Studies show that EHRs pay for themselves within a few years and then generate profit partly because of facilitated coding, not greater practice efficiency. [EHR's saving the government money? A pipe dream - ed.]

Partial list of references cited in the excerpts above:

[3] Park T, Basch P. A historic opportunity: wedding health information technology to care delivery innovation and provider payment reform. Washington, DC: Center for American Progress, 2009. (

[4] Hartzband P, Groopman JG. Off the record — avoiding the pitfalls of going electronic. N Engl J Med 2008;358:1656-8.

In fact, I'd made similar observations about an ED EHR in a hospital where a relative was treated. I wrote:

... I reviewed a printout from the ED system myself, and found a collection of what I call “legible gibberish” (a mass of information as if the EMR system is just a warehouse for clinical data) but no diagnosis of her problem. A nonspecific and non-useful diagnoses of “abdominal pain” was all I could find – and that was on page 8 of an 12 page printout.

... These observations and events cause me to believe your electronic medical records systems are not serving the patients and the physicians properly and could result in patient harm.

The outputs of inpatient EMR's are far worse. See my Feb. 2011 post "Two weeks, two reams." The thousands of pages of data-dumped legible gibberish I've seen has been stunning, both in terms of the ignorance of basic information science and the wasted effort and dangers to patients represented when other physicians need to refer to these old records in caring for sick people.

Berenson et al. add to our understanding of these phenomena.

-- SS


Anonymous said...

The progress note has become the bill and provides meaningfully useless and obfuscated clinical information. I stopped reading the boilerplate and template notes of even the most revered specialists and consultants.

Live IT or live with IT said...

Automate a bad process and you get a bad automation. E&M coding has been a joke for years and seems to provide negative value. As usual, the path to hell is paved with good intentions....

Anonymous said...

Shocker... this is what happens when non-clinicians start trying to 'optimize' the process of delivering health care. They set up well meaning but intrinsically stupid criteria for 'quality' then wield a financial club to encourage compliance (and 'incidentally' decrease reimbursements...) What you end up with is a perversion of the system.

There is nothing I hate more than reading through the data dump when a patient gets transferred to my ICU from a small hospital. Give me a good transfer note written by an informed physician who knows the patient well.

whatevs... EMR and it's retarded stepchildren are not going away, we have to learn to deal with it. But I admit, I fantasize about switching to an all cash business so I can stop writing BS in the chart, stop fighting with insurance companies and go back to taking care of my patients.