There is a recent and interesting piece in the Washington Post by an orthopedic surgeon, Dr. Craviotto, about the maddening aspect of forced mandates and bureaucratic requirements in medicine that seem to have very little to do with actual medical care and more about hoops through which we must jump that seemingly lead to nowhere.
While I do find the bureaucracy of medicine in the United States insane versus the Canadian system (for example) I was interested in Dr. Craviotto’s take on the burden of the forced electronic health record (EHR) mandate and the time that doctors spend filling out “unnecessary fields” to satisfy regulatory measures. Dr. Craviotto writes that his isn’t an unique complaint, quoting a study commissioned by the American Medical Association that identified “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”
I am just going to have to stand up and say I love my electronic health records. Really. I really do. I’d like to give the perspective of an early adopted from a fully integrated system.
First of all, I don’t find electronic charting more cumbersome than traditional notes by hand. I can dictate with my voice recognition system or type. I have to write something regardless, so I don’t understand how EHR makes that worse unless of course the few chicken scratches jotted down while talking with the patient was actually the note? Back in the bad old days of paper charts there were many times I’d look for a colleague’s note and find 3 lines, 2 of which I couldn’t read. If the note were dictated it was usually complete, but very often handwritten notes were the norm (and incredibly short and less than adequate, legibility issues aside). I have probably been guilty of that myself. Perhaps EHR encourages doctors to write a little bit more? I’m not sure how that’s a bad thing unless you get carried away and contribute to chart bloat.
Then there is the fact that I always have the patient’s record. I estimate back in the day of traditional charting that I was missing 10-30% of the charts each clinic day. Not having the patient’s information is so incredibly cumbersome and I do believe it impacts care. I have struggled incessantly trying to piece together a previous physician’s plan or to figure out what actually happened in the emergency room more times than I can remember with paper charts. How many times have I ordered a test because I just couldn’t find the result (maybe the lab forgot to draw it or maybe they couldn’t read what I wrote?) only to find some rogue slip of a lab result that was incorrectly filed two days later. Now, I order my lab tests in the EHR, the lab generates the label from the order so nothing ever gets lost in translation, and the results load immediately into the system and then directly into my inbox.
Outside records? They get scanned in, but as more and more systems come online I can link with them. Imagine the freedom of not having to send those record release forms that seem to never, ever get answered!?
What about prescriptions? My system is fully integrated with pharmacy. Many patients can’t remember their medications or doses. With EHR they’re right there. Some patients tell me they took the medication that I prescribed, but looking at the EHR sometimes I find they did not so then we can talk about how and why that happened. Consider the following scenario:
Me: “What kind of estrogen did you try Mrs. Smith? The cream, the tablet, or the ring?”
Mrs. Smith: “Oh, I don’t know doctor it was so long ago, but whatever it was really irritating so I’d like something else.”
Instead of taking a guess and potentially having the patient buy an expensive medication she doesn’t want to use or call the pharmacy (if she can remember which pharmacy she used back then) to see if they can possibly track down what Mrs. Smith had in 2006, 2007, or 2008 (she thinks) and then me or my nurse calling Mrs. Smith back the next day if we get the answer, I simply click the medication tab, wait 5-10 seconds while all the previous meds load, organize by alphabet, and there it is. She tried Premarin cream in 2005 so now I can give her something else. Today. Three clicks and 30 seconds of work instead of three phone calls (me calling the pharmacy, them calling me back, and then me calling Mrs. Smith) that still may not gather the right information.
Not only is everything at my finger tips (including radiology images and labs), but the e-mails that my patients can send me through EHR are also there as well as the attachments that they can send. With a couple of clicks and about a minute to load the image I can reassure the patient that the “cyst” on her ovary that she was worrying so much about is 4 cm and simple and so not a cancer concern. I can also reframe my discussion of my patient’s report of not having diabetes with her previous HgBA1C of 8%.
What do I find cumbersome? Well, at the beginning it was very new and change is hard. However, I am one of the minority of doctors who has been using EHR exclusively for over 7 years so I’m pretty facile now (and I’m no computer whizz, IT cringes when I call). I also have access to doctors who are computer gurus who routine share tips and tricks as well as tech experts whose sole job is to help me use my EHR better.
What about the coding and things that are part of the Medicare requirements? I had to code before EHR. That entailed a large sheet with columns of codes and I had to circle each one and then write the ones in by hand that were not there. To find the ones not listed I either had to call my coder or do an Internet search. Now, I just type the conditions or symptom into a field and the code pops up.
The only slightly annoying thing to me is the prescribing. Occasionally I forget to click the right pharmacy and then in a panic after the patient leaves I have to make a phone call to get the prescription switched to the right place.
I do get annoyed by the fields I have to fill out that seem completely unrelated to patient care and more about metrics for Medicare, especially given Medicare hasn’t been using those metrics too wisely otherwise how would an opthalmologist in Florida bill Medicare $21 million a year! I would have to do all that Medicare drudgery regardless, so that’s not the fault of my EHR. (Note to Medicare, hope you are investigating that $21 million a year practice).
Some doctors are such efficient typists they can chart electronically while seeing patients. Might that enter an element of “computer chill” and result in less face-to-face time for the patient? I think it depends on both the doctor and the patient. Some doctors will interact better than others while using technology, but I do think as more and more people become so technology focused that perceptions of electronic charting interference might change. Any office using EHR could easily anonymously survey their patients and find out who feels charting on the computer interferes with the visit and who doesn’t and adjust accordingly.
My children’s pediatrician moves effortless between the computer and my kids and doesn’t seem to make it impersonal at all. My kids use computers at school, they use them at home, so why wouldn’t their doctor also use them in the office? They aren’t even learning cursive at school because according to the school no one writes anymore. They get keyboarding skill assignments, not writing practice. Do we really think a 10-year-old who is destined to be a doctor in 15 or so years will be writing much of anything by hand? Will anyone?
At the airport last year one of my kids asked, “What’s that?” It was a paper airplane ticket. The old-fashioned kind. They had no idea that anyone ever did anything else than book electronically. Would anyone of us want to call the airline, wait on hold until you get an agent, book a ticket, and then wait for it in the mail and hope you don’t lose it?
I am not that good of a typist and my notes are typically long so I still takes notes by hand (traditional face-to-face, as it were) in the room and chart later, but I did that before EHR. I have to either look at a paper or a computer screen while I’m seeing a patient, so there is always going to be some kind of charting interference. It’s possible that using a tablet might help take away a barrier that computer screens might generate as, ironically, it is about the size of a clipboard that many doctors (myself included) carry into rooms now on which to write.
I can’t help wonder if most physician complaints with EHRs stem from poor systems, inadequate training and support, or smaller offices and solo practitioners who can’t tap into a larger network to really optimize their EHR.
Should EHRs be mandated? That I don’t know. I think to mandate something you need clear studies to show it saves lives or improves health. It is important to look at the burden on solo practitioners, because different practices will have different challenges. All I know is having complete and legible information up front allows me to give better medical care. EHR hasn’t degraded my clinical documentation, but improved it.
To me paper charts are a puzzle with missing pieces and you just never know if you’re missing a key piece or not.