cancer, creative destruction of medicine, digital media, ehr, emr, eric topol, healthIT, oncology
By Richard Just, MD
My group purchased our Electronic Health Records system (EHR) about 5 years ago. We had 4 clinical practice locations (soon to be 5 ½) with 1 administration office. None of these sites are close to each other. A major reason for purchasing an EHR was, and still is, to collect and analyze all data from our entire practice for the purpose of determining outcomes of our treatments. In other words, we wanted to know how our patients were doing in all of our offices, which treatments were working and which were not, and then use this information to refine and practice the best medicine we could. This was the promise of EHR.
And so my nightmare began. Some of my patients define nightmare as something you didn’t wish for and it never seems to end. Volumes could not fully describe my experiences. I’ll just mention one “glitch”: I noticed that some of my notes were disappearing into the ‘ethernet’ on a seemingly haphazard basis. Sometimes I could locate them in another section of the chart; other times I wasn’t so fortunate. Despite my staff spending weeks trying to find the defect, we had no success. Our vendor monitored my work processes for two weeks. Again, clueless. To add insult to injury, I was told that I was the only one experiencing this problem which, of course, I took personally. Turns out the problem occurred only when I started my note before my Medical Assistant entered vital signs. So we had the explanation, but no fix. As a result, I wait for my MA to enter her data, which frequently delays my ability to see patients on time. Recently, we have added 2 physicians to our practice. One of them asked me what he was doing incorrectly that caused some notes to disappear. This time I had the answer!! What’s more, I was now informed that it was a system wide problem for which there was still no fix.
When I was a kid, there was a TV show called the Naked City. When episodes ended, the announcer said: “There are 8 million stories in the Naked City; this has been one of them.” I do know that my story is just one among many. But it’s still so annoying. Because of the flawed design of this particular EHR system, we have been burdened with huge financial costs resulting from lost time, the need for extra IT support, and the hardening of my right carotid artery. I don’t need the added stress in this era of decreased reimbursements for providing clinical care and chemotherapeutic agents. One of my partners has gone back to hiring a transcriptionist rather than using the EHR. Another is chronically behind in his data entry. To this date, we are not set up to pool and analyze our data for outcomes. Soon, we are beginning the gut-wrenching process of converting to a new, and hopefully more user friendly, system.
A few weeks ago, I had the pleasure and honor to have a conversation with Eric Topol, M.D. on ‘this week in oncology‘ radio radio show. We were both intrigued by two articles that recently appeared in the New England Journal of Medicine on this subject. The first, entitled “Escaping the EHR Trap—The Future of Health IT”, discredits the myth propagated by EHR vendors that health IT is different from industrial and consumer IT. The authors suggest that vendors have alleged this to be fact “in order to protect their prices and market share and block new entrants.”
The second article is also quite enlightening: “Unraveling the IT Productivity Paradox—Lessons for Health Care.” In the 1970’s and 80’s, many industries adopted computers with the expectation that they would increase productivity. To everyone’s surprise, digitization resulted in a significant reduction in efficiency. This was called the Productivity Paradox. Subsequent research revealed that productivity attributed to computerization was underestimated due to defects in measurements, mismanagement of processes (such as summarized in the “glitch” in my system above), and poor usability. Most systems, including mine, don’t have spell-checking capability. Unbelievable!!
In chapter 7 of his must read, “The Creative Destruction of Medicine”, Dr. Topol discusses the benefits and challenges of Electronic Health Records and Health Information Technology in detail. Despite the fact that digitization initially can be associated with an increase in errors, which doesn’t ease my pain, and many other challenges, he concludes: “While some may consider the topic of electronic medical records prosaic, it should now be abundantly clear that their ultimate adoption and full interoperability will prove fundamental to the future of medicine. Only via full electronic convergence can all the tools of digital medicine be in sync and immediately useful. With the torrent of individualized data flow that is coming from whole genome sequencing, remote physiologic monitoring, and medical imaging, electronic information storage and processing will become more essential than even envisioned today.”
I have to agree with him. While this current transition period can be a frustrating, even painful experience, the alternative of a failed health care system is unacceptable.
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Peter Maas said:
As an IT consultant that manages EHR systems I believe that a good portion of the problems in EHR systems is the lack of accountability of the software providers. The ‘It’s just you’ excuse that is very common would quickly evaporate if there a FCC like reporting system of open records on problems in EHR software. EHR vendors would no longer be able to hide behind a cloak of obscurity.
I have seen glaring security issues stay in products for years. The vendors will say firewall the system, but the security flaw is related to nurses who shouldn’t have access to delete Dr’s notes being able to remove them from the system like they never existed. Yes, it could be found in an audit, but there are no easy ways to audit the system. Authentication and consistency checking on records in many cases is non-existant.
Many public systems on reporting computer vulnerabilities such as CVE exist, also organizations such the the FTC and FCC already exist for a consumer dealing with a provider, why does EHR get a free pass behind a hidden curtain when its issues can effect our life the most?
S Silverstein MD said:
First: perhaps he has not paid enough attention to literature such as this: http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html
Second: what is the evidence that his projections are “abundantly clear” in 2012? At best there is conflicting evidence on that prognostication.
Third: the attitude that a clinic full of non-consenting patients is an appropriate testbed for alpha and beta clinical software that puts them at risk is medically unethical, based on the guidelines developed from medical abuses of the past. There is nothing to argue or debate about this.
The solution is to treat health IT as another medical device, and use the methodologies of human subjects research to improve the devices, not the current unregulated experimentation that is the norm.
S Silverstein MD said:
No surprises here. See http://www.ischool.drexel.edu/faculty/ssilverstein/cases/ and the many stories of health IT difficulties at http://hcrenewal.blogspot.com