Wednesday, January 31, 2018

The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging

In recent days, I've posted about current articles on the destructive nature of today's vastly over-complex, burdensome EHR technology.  These posts included "Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records" at
and "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at

There are many other earlier articles of a similar nature discussed on this blog, e.g., the May 2017 post  "Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records" at for one, and others retrievable by query links, and similar.

Here's another recent article along the same lines that just appeared in the prestigious New England Journal of Medicine:

Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians
Alexi A. Wright, M.D., M.P.H., and Ingrid T. Katz, M.D., M.H.S.
January 25, 2018
N Engl J Med 2018; 378:309-311

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care.

I note that, unlike this primary care physician, many physicians have to learn numerous EHR's and use them simultaneously if they provide services at different healthcare systems. 

Channeling the satirical medical internship novel "House of God" and its "law #11" (, full movie at, these poor souls are probably constantly thinking "find me the EHR that only triples my work and I'll kiss your feet."

“We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

That is a prescription for suboptimal performance and increased risk of harm, on its face.  There is little to argue on that point.  I personally would not want an airline pilot, let alone a physician, providing me services who is "disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

Increasing clerical burden is one of the biggest drivers of burnout in medicine. Time-motion studies show that for every hour physicians spend with patients, they spend one to two more hours finishing notes, documenting phone calls, ordering tests, reviewing results, responding to patient requests, prescribing medications, and communicating with staff.1 Little of this work is currently reimbursed. Instead, it is done in the interstices of life, during time often referred to as “work after work” — at night, on weekends, even on vacation.

That is, quite frankly, an absurd workload deleterious to provider AND patient well-being.

“EHRs can be a double-edged sword, because they give you more flexibility about where you work, enabling physicians to get home for dinner,” argues Tait Shanafelt, professor of medicine at Stanford University and a leading researcher on physician burnout. “But physicians are working a staggering number of hours at night, and this has enabled organizations to continuously increase productivity targets without changing the infrastructure or support system, effectively adding a whole extra workweek hidden within a month.”

Imagine trying to force "a whole (uncompensated) extra workweek hidden within a month" to the workload of a union member of, say, the Transport Worker's Union.  It would result in an instant labor strike ... or worse.

... Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.3

I rest my case on the increased-risk-of-harm issue.

I seem to be one of the first to recognize, or at least start writing openly about, the bad leadership of the health IT field and the dangers of the bad health IT produced as a result.  My observational skills and critical thinking capabilities led me to start writing on these issues circa 1999, after my experiences as postdoc and faculty in Medical Informatics at Yale School of Medicine/Yale-New Haven Hospital and then as CMIO at the Christiana Care Health System in Delaware. 

That writing is largely retained at, in a website I have not updated in several years due to time constraints related to the EHR forensics work I have been doing in the legal and law enforcement sectors.

It is clear my concerns are now proven correct and are now being echoed by large sectors of the physician and nursing communities.   My concerns were obvious, I opine, to anyone of reasonable critical thinking and observational skills, who were not affected by conflict of interest.  That is, those without profitable connections to the health IT industry.

I now make a prediction for the future that, once again, seems obvious to me:

Today's EHRs, especially the sections for narrative clinician documentation, will be downgraded from their "template madness" time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper.  Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s' as at, but paper nonetheless.  Data extraction of these notes for financial purposes will be done, once again, by coders.

A small sample of why physicians and nurses burn out from EHRs.

Debate if you will, but that is my prediction for the future.  I feel it inevitable considering the unintended/unexpected terrible consequences and realities of this technology.  "New curtains" (that is, tidying up the user interfaces) will not suffice.  This is a prediction from one of the first Medical Informatics professionals to start openly writing about EHR difficulties almost two decades ago. 

-- SS


Darrell said...

Excellent, Scot.

Dr Joe said...

Paper notes with data points extracted by coders is exactly what and EHR should be. The paper note gives the writer the flexibility and reliability of a process that has been effective for over a thousand years. The image of that document gives transportability and is compatible with any device that can read a document image. The coding can be done by others for whatever suits the suits that month.

Anonymous said...

More like two thousand years for paper. The Dead Sea Scrolls are probably that age. On other media, writing goes back far further, such as a 14th century B.C clay document,

However, old stuff is irrelevant to the technology-happy.

Unknown said...

EHRs are very important in today's society. Having EHRs simplified would mean going back to paper charting in some aspect. With advanced technology, EHRs has allow physicians, doctors, nurses and other ancillary services access patients health records. When I think simplifying EHRs, I think about one of the biggest crisis in America, the opioid crisis. A lot of patients/drug abusers go from hospital to hospital, doctor to doctor, and clinic to clinic to get prescribed pain medications. Working a as a team, EHRs has allowed the healthcare industry to track patient records (health history, surgeries, medication history, labs, and x-ray). Documentation is an assets that is necessary in healthcare to prevent liabilities.


InformaticsMD said...

The blank-profile "Valerie Jiles" said:

"BLAH, BLAH, I did not read the material presented and am dumping the usual pro-HIT industry boilerplate with a huge non-sequitur thrown in regarding when I think of simplifying EHRs plus some grammatical errors as well."

I wish to thank "Valerie" for his valuable contribution to our site.

-- SS

InformaticsMD said...

The no-profile (anonymous) "Valerie Giles" claimed to be a nurse and left more pro-industry boilerplate that was entirely non-responsive to my post.

As such, the comments will not appear here. The truth is, most clinicians loathe EHRs in their present state. Mere window dressing will not correct it.

-- SS