• The more docs use EHRs, the less they like them

    Long time readers of the blog know of both my love of information technology and my skepticism that they’re going to be widely accepted (and bring down costs) in the near future. There’s a new report out of the AMA news that supports my beliefs:

    The meaningful use incentive program has resulted in more physicians implementing electronic health record systems and using them in advanced ways. Yet doctors’ dissatisfaction with the systems has increased.

    Theories for what is driving the dissatisfaction include rushed implementations, too little training and physicians doing too much too soon as they struggle to meet meaningful use requirements, other federal mandates and changes to the health care landscape. EHR vendors also are thought to be taking on too much in too little time. As they rush to deliver products certified for meaningful use, usability may have suffered.

    Some data? AmericanEHR partners did a survey of more than 4200 providers, and found that satisfaction with EHRs dropped from 39% to 27% from 2010 to 2012. At the same time, the percentage of them who were “very dissatisfied” nearly doubled. Here are some more details:

    Would not recommend their EHR to colleague24%32%39%
    Would not purchase their EHR again25%30%38%
    Very dissatisfied with ability to decrease workload19%25%34%
    Dissatisfied with EHR features and functionalities20%27%32%
    Dissatisfaction with ease of use23%32%37%
    Very dissatisfied with ability to improve patient care10%14%20%
    Very dissatisfied overall with EHR11%15%21%

    So while more and more physicians are adopting (or being forced to do so), they’re becoming more and more dissatisfied with them. I’ve discussed why this is so in the past. Just mandating docs use them is not going to work.


    • The issue I’ve found is data entry is timing consuming, prone to errors, and wading through “screens” on an EHR is laborious. Writing handwritten notes, visually scanning your own notes offers some contextual advantages that jog memory and enable faster mental processing.

      In 2000, when interviewing at Greenwich Hospital in CT for internship I noticed they still had paper, but they scanned the notes which were they available in the EMR for easier retrieval. I wonder if this is still being done.

      An EMR has two/three purposes, to allow for easier retrieval of historical information and presentation of that information to “improve” diagnostic or treatment efficiency. The third is financial and allows for billing/reimbursement efficiency…which actually has been used to increase costs by optimizing billable coding.

      I’m not in the camp that the second purpose has been met or can be met. Big Data access to healthcare information is a dangerous slippery slope, and I’m not sure if googlifying the raw data will help patients in the long run. A Google books as an EMR may be entirely a different story.

      IMHO, digitizing information like glucose testing is better on a smart phone with the patient involved.

    • See the fiesty twitter hashtag #EHRbacklash

    • EMR’s are going to be useless until either physicians abandon the free-text note as their primary mode of information exchange or natural language processing advances enough to decode these notes. Look at all the industries that have successfully implemented digital information exchange over the last 2 decades and you’ll find one thing in common: structured data.

    • [Note from Austin – I do believe the quote is of Aaron, not me.]

      Austin writes: “Long time readers of the blog know of both my love of information technology and my skepticism that they’re going to be widely accepted (and bring down costs) in the near future.”

      I think you were very prescient. IMO in order for computer records to develop in an efficient way it has to be organic, ground up. What is presently being attempted is to mandate how the EMR should function and what it should contain in part to satisfy the needs of other parties rather than the physician’s needs.

      These efforts are resented in part because the government is trying to get your dad to practice in the bureaucratic fashion something he was never trained to do. Physicians and certain other groups have to think fast and cannot use the typical bureaucratic methods. Government officials would benefit greatly from reading the following book which is fascinating and helps one understand how decisions are made (That includes physicians).

      Sources of Power: How People Make Decisions by Gary Klein (Feb 26, 1999)

      ” How do these individuals make the split-second decisions that save lives? Most studies of decision making, based on artificial tasks assigned in laboratory settings, view people as biased and unskilled. Gary Klein is one of the developers of the naturalistic decision making approach, which views people as inherently skilled and experienced. It documents human strengths and capabilities that so far have been downplayed or ignored.”

      • I agree with much of what you say, but it wasn’t the fault of government. Plenty of private insurers, as well as hospitals, got in the way and made up their own rules and regulations as well. My father has no special love of government, but this is one thing he didn’t blame them for.

        • Aaron, government is us. We determine the type of society we live in. I don’t like to peek into my neighbor’s window and tell him how to run his life. On the other hand I will gladly help my neighbor if he needs it.

          Everyone gets in the way, but government leads the pack where Medicare is concerned. Good government should be the final arbiter, the one that levels the playing field, but once government becomes a player it can no longer function as an impartial referee. It is not my dislike for my government that I oppose its unnecessary interference into our lives rather my great love for my government and wishing it not to become tyrannical.

          I think the above adequately describes the different approaches we each might have with regard to society as a whole. Perhaps the basis for this is our respective interpretations of history and how we define our heroes and villains.

          Your father practiced medicine at a time when government was not so involved in the minutia of medicine and he didn’t have the time to think about these things in depth much less talk about them. His time, skills and knowledge were utilized much more efficiently than what we see today. (I am talking about hour by hour comparisons based upon the technology of the day not the total amount of time he spent devoted to the practice of medicine.) For many what your father did was a necessity, as life was not as easy as it is today where one has many of the luxuries earned by earlier generations of Americans.

          • Now you’re lecturing me on the history of my father, his EHR, and his practice? Really?

            I was there!

            • My comments weren’t offered as a lecture only a different perspective. I was talking about your father from an historical perspective of many physicians from that generation, not from a personal one. I used your father as the generic physician that practiced 24/7. (“**For many** what your father did …” ” Your father practiced medicine **at a time**” )

              You brought your father into the 1)discussion and 2)added a value judgement: “My father has no special love of government, 2) but this is one thing he didn’t blame them for.”

    • At present, EHRs are designed primarily to aid with billing and to help administrators collect data. When they are designed primarily to help physicians do their work, we will like them.


      • ….and also to help attorneys gleen through records easier.

        Anyway, I agree with you. Every day I feel I am entering information that’s more important to pencil pushers and accountants than to me, other doctors, or my patinets.

    • It’s the future of healthcare; physicians need to get over it and adapt.

      • It might be the future, but is the EHR of today the correct future and is it inhibiting the appropriate practice of medicine?

      • When users have to adapt to the product, and not the other way around, the product has a poor future. I use a computer record written by a local programmer for a small surgicenter where I sometimes work. Absolutely no demographics in it, other than what it is already entered into the system when the patient is signed up for their surgery. I check 5 boxes, enter drug amounts and that is about it. When I look to buy a system for my tertiary care facility, I need it to be able to integrate with the hospital system. This greatly limits my choices, and they all suck. They all require at least 5 minutes of data entry before I can get to pertinent pt care stuff. As I take care of a lot of kids, and some of the case can last less than 15 minutes, I really dont want to spend more than 1/3 of that time doing data entry rather than paying attention to the kid.


      • Patients will have to adapt to the inefficiencies, longer wait for appts and less physician -patient time as we will be entering data for the pencil pushers.

    • The negatives numbers are certainly high, but the trend does not necessarily tell us if things are getting worse, or if it is a reflection of the difficulties experienced by new, less enthusiastic users. It is hard to tell how the survey was conducted, but the 2012 survey includes later adopters, some of whom were adopting later because they were apprehensive to begin with. I am not suggesting this is not a problem, only that the trend may not reflect a worsening situation, but a reflection on the broader reach of EHRs.

    • If people would only use my state-of-the-art Meaningful Use Certified product, all of this carping would evaporate.



    • This mostly sounds to me like a user interface problem screaming to be solved. Which means there is a market opportunity for dissatisfied physicians to design something that works for them. So go find a talented designer with software skills, figure put what you need, and fix it.

      I’m of the opinion that we are in a ‘pay it forward’ phase with EHRs at the moment. Today they help with billing (and despite the comment above about paper pushing, given the massive underwriting of many unprofitible employed physicians by hospital groups and the like, revenue is a very important factor.)

      Tomorrow? With big data mining, ‘Dr Watson’ type solutions being around the corner, smart phones feeding in remote monitoring data – the EHR provides a natural home and data source for the coming algorithmic revolution in healthcare. Having a few years worth of data sitting in EHRs should prove to be extremely valuable when this stuff starts to hit – even if it takes advances in reading free text entries. Which is also happening in other industries – for example, legal discovery work (ie reading documents) has been automated by software.

      Almost every other major industry crossed this threshold long ago. In many cases, the immediate payoff to a structured data approach wasn’t obvious – for example, why do I need a computerized point of sale terminal to sell movie tickets? But just a little bit down the road, and I can now purchase admission on my smartphone, due to the underlying ticket selling infrastructure.

      So IMHO, we are in a ‘Build it and they will come’ phase.

      • “the coming algorithmic revolution in healthcare…”

        This is a faith based statement and inherently not scientific.

        Providers having the time to listen and care for patients and not just seeing them as “data” to manage and then exploit (for profit) is what will improve health-care rather than sick-profit.

        There is an position in between luddite and “kurtzweilian”, which states that progress through technology CAN occur but is not guaranteed. The metric used to measure the progress is often the most important and often exploited technique to justify progress in the face of regress.

        “So go find a talented designer with software skills, figure put what you need, and fix it.”

        “Talent” is a combination of aptitude and experience (hard work) . If a programmer has programming aptitude it doesn’t mean they have healthcare aptitude and it definitely doesn’t mean they have years of experience designing, nevertheless using, healthcare software to improve wellness.

    • I think one fo the reasons that docs hate EMRs is that the purchasers (hospital administrators) are not the end users (physicians), so the product is geared towards the priorities of the purchasers. Huge enterprise-wide systems are adopted which are fully buzzword-compliant and deliver lovely reports to management, but scant attention is paid to the human interface and workflow, so the users hate it.

      There are exceptions to this rule, but I suspect this is a larger-than-recognized cause of docs hating on the EMR.