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Documenting To Death: Are EMRs Eroding The Soul Of Medicine?

Electronic medical record systems (EMRs) have become a part of the work flow for more than half of all physicians in the U.S. and incentives are in place to bring that number up to 100% as soon as possible. Some hail this as a giant leap forward for healthcare, and in theory that is true. Unfortunately, EMRs have not yet achieved their potential in practice – as I have discussed in my recent blog posts about “how an EMR gave my patient syphillis,” in the provocative “EMRs are ground zero for the deterioration of patient care,” and in my explanation of how hospital pharmacists are often the last layer of protection against medical errors of EPIC proportions.

Considering that an EMR costs the average physician up to $70,000 to implement, and hospital systems in the hundreds of millions – it’s not surprising that the main “benefit” driving their adoption is improved coding and billing for reimbursement capture. The efficiencies associated with access to digital patient medical records for all Americans is tantalizing to government agencies and for-profit insurance companies managing the bill for most healthcare. But will this collective data improve patient care and save lives, or is it mostly a financial gambit for medical middle men? At this point, it seems to be the latter.

There are, however, some true benefits of EMRs that I have experienced – and to be fair, I wanted to provide a personal list of pros and cons for us to consider. Overall however, it seems to me that EMRs are contributing to a depersonalization of medicine – and I grieve for the lost hours genuine human interaction with my patients and peers. Though the costs of EMR implementation may be recouped with aggressive billing tactics, what we’re losing is harder to define. As the old saying goes, “What good is it for someone to gain the whole world, yet forfeit their soul?”

Pros Of EMR Cons Of EMR
Solves illegible handwriting issue Obscures key information with redundancy
Speeds process of order entry and fulfillment Difficult to recall errors in time to stop/change
May reduce redundant testing as old results available Facilitates excessive testing due to ease of order entry
Allows cut and paste for rapid note writing Encourages plagiarism in lieu of critical thinking
Improves ease of coding and billing to increase reimbursement Allows easy upcoding and overcharging
Reminds physicians of evidence-based guidelines at point of care Takes focus from patient to computer
Improves data mining capabilities for research and quality improvement Facilitates data breaches and health information hacking
Has potential to improve information portability and inter-operability Has potential to leak personal healthcare information to employers and insurers
May reduce errors associated with human element May increase carry forward errors and computer-generated mistakes
Automated reminders keep documentation complete May increase “alert fatigue,” causing providers to ignore errors/drug interactions
Can be accessed from home Steep learning curve for optimal use
Can view radiologic studies and receive test results in one place Very expensive investment: staff training, tech support, ongoing software updates, etc.
More tests available at the click of a button Encourages reliance on tests rather than physical exam/history
Makes medicine data-centric Takes time away from face-to-face encounters
Improved coordination of care Decrease in verbal hand-offs, causing key information to be lost
Accessibility of health data to patients Potential for increased legal liability for physicians

Hospital Pharmacists: Protecting Patients From Electronic Medical Record Errors May Be Their Most Important New Role

Most hospitalized patients and families don’t realize that life-threatening medication errors are regularly thwarted by pharmacists. They are truly the unsung heroes of patient care. I just finished a locum tenens assignment at a hospital that uses EPIC as their electronic medical records system, and I was stunned by the impossibly complex medication reconciliation process. Each time a patient is admitted to the hospital, or transferred to another part of the hospital, a physician must review, approve, and re-order their medications. While this may seem like a good way to insure that medication errors are avoided, it actually has the exact opposite effect.

Because EPIC keeps lists of home meds, discontinued meds, and current meds available for review and reactivation, it takes little more than one misplaced check box to order the wrong dose or type of medication. Physicians who transfer a patient to another service can indicate their intended medication list and keep it “on hold” for the receiving physician to review and approve. Unfortunately, the software’s tab system is so complex that it’s extremely difficult to find that list and activate it. Lost in a sea of admissions tasks and order boxes in different fonts, colors, and drop down menus, one often accidentally reviews and approves discontinued types and doses of medicines. The only protection against such errors is the hospital pharmacist.

With each new admission to the inpatient rehabilitation unit, I had to resort to calling a pharmacist for help. I was terrified that I would accidentally insert medication errors into the patient’s order set by carrying forward discontinued meds. The long-suffering pharmacists explained to me that “most physicians make medication order errors in EPIC with each admission.” They said that they regularly had to talk physicians out of throwing their computer out the window in a state of extreme frustration. They also said that their EPIC user environment looked very different (and less confusing) than what the physicians used, so that they couldn’t even provide real-time phone guidance regarding order entry process.

The scary thing is that EPIC has the largest market share of any EMR in the United States. It is also (in my experience) the most prone to medical errors due to its overly complex medication reconciliation process. I have used other EMRs that have far simpler and more intelligent medication order entry processes. Soarian (Sieman’s EMR, just sold to Cerner) has, for example, an outstanding order entry system. So my complaint is not that “all EMRs are bad” – it’s that some have particularly flawed designs that are causing real harm to untold millions of patients. We just haven’t documented the harm yet. I tremble at the thought of what we’d find.

Until electronic medication reconciliation is made safer, pharmacists will be working overtime to correct records and protect patients from carry over errors. I thank my lucky stars that I have had vigilant, determined pharmacists by my side as I cared for very complex, sick patients who were exceptionally vulnerable to dosing errors. There has never been a more important time to exercise caution when entering hospital medication orders, or to express your appreciation for pharmacists. Without their help we might all be experiencing medication errors of EPIC proportions.

Five Things That Electronic Medical Records (EMRs) Can Learn From Social Media

As a physician who openly despises many aspects of current EMRs (see “How An EMR Gave My Patient Syphilis” or “The Medical Chart: Ground Zero For The Deterioration Of Patient Care” ) I recognize that they are here to stay. And so, since we’re all stuck with these digital middlemen, I have some suggestions (based on popular social media platform functionality) for making them better.

1. Likes. Healthcare providers should be able to “vote up” an excellent note in the medical record. Let’s face it, not all doctors are equally good at documentation. Untold hours of our time are spent trying to cull through pages of auto-populated, drop-down-box checks to figure out what’s actually going on with a patient on a particular day. Once in a while you stumble upon some comprehensive free text that a physician took the time to type after a previous encounter, and suddenly everything becomes clear. If there were a way to flag or “like” such documents, it would help other readers orient themselves more quickly to a patient’s history. A “liking” system is desperately needed in EMRs and would be a valuable time saver, as well as encouragement to physicians who document notes well. Hospitals could reward their best note makers with public recognition or small monetary bonuses.

2. #Hashtags. Tagging systems are sorely lacking in medical records systems, which makes them very difficult to search. Patients make multiple visits for various complaints, often with numerous providers involved. If physicians had the ability to review notes/records unique to the complaint that they are addressing, it would save a lot of time. Notes could be tagged with keywords selected by the author and permanently recorded in the EMR. This would substantially improve future search efforts. Even if the EMR generated 10 search terms (based on the note) and then asked the physician to choose the 3 most relevant to the current encounter, that would be a step in the right direction.

3. Selfies. Medical records would benefit from patient-identifier photographs. In a busy day where 20-30 patients are treated and EMR notes are updated after the patients have gone home, a small patient photograph that appears on each documentation page will serve the physician well in keeping details straight. Patients should be able to upload their favorite portrait to the EMR if the standard one (perhaps taken during the intake process) is not acceptable to them. In my experience, nothing brings back physical exam and history details better than a photograph of the patient.

4. Contextual links. All EMRs should provide links to the latest medical literature (on subjects specifically related to the patient’s current diseases and conditions) in a module on the progress note page. and other reference guides could easily supply the right content (perhaps based on diagnosis codes). This will help physicians practice evidence-based medicine and keep current with changes in recommended treatment practices.

5. Microblogging. Sometimes there are important “notes to self” that a physician would like to make but don’t need to be part of the official medical record. EMRs should provide a free-text module (like a digital sticky note) for such purposes. These sticky notes should not be admissible in court as part of the medical record, and should not be uploaded to the cloud. Content included in these notes could include social information (patient’s daughter just had a healthy baby girl), hunches (patient looks slightly pale today – will check H&H next time if no change), and preliminary information (remember to review radiology result before calling patient next Tues).

It is my hope that EMRs will slowly adopt some best practices from top social media platforms. After all, if millions of users are effectively using voting, tagging, linking, searching and imaging in their daily online lives, it only makes sense to capitalize on these behaviors within the constraints of the medical environment. Maintaining strict confidentiality and appropriate professional boundaries (often missing in the social media world at large) is certainly possible with EMRs. Let’s build a better information capture and retrieval process for the sake of our patients, and our sanity.


At least one EMR is already providing #3 and #5 as part of its software: see Are you aware of any others already implementing these ideas?

Do Elite Academic Centers Provide Better Hospital Care?

A well-to-do patient recently boasted to me about an expensive insurance plan that he had purchased to “guarantee” that he had access to the best healthcare in the United States. Coverage included access to elite academic centers (all the usual suspects) and a private jet service for emergencies. He was utterly confident that his investment was worth the price, but I withheld my own misgivings.

Hospital quality data suggest that “fancy, brand name hospitals” provide better patient care. But unfortunately there is no guarantee of good outcomes for anyone who sets foot in a hospital. My experience doesn’t exactly square with quality data, and although I realize that there are teams of public and private sector analysts out there furiously rating and ranking hospitals with all manner of outcomes data, I don’t think it means a whole lot for the individual “worried well” patient. Here’s why:

1. Higher overall patient complexity may mean less attention for you. Academic medical centers specialize in caring for those who are often too sick or too complicated to be cared for elsewhere. This means that each patient requires more staff time to address their long list of diseases and conditions. Everything from medication reconciliation to medical testing, to bedside care, requires more time from each provider taking care of them. If you happen to be on a medical floor with complicated neighbors, expect to see less of your doctors and nurses. It’s not fair, but this happens regularly at elite centers, and it’s not in your best interest.

2. Less-experienced physicians may be providing the bulk of your care. Academic teaching hospitals are actively involved in training young doctors, and the least experienced among them will likely be providing the majority of your care (and reporting up to the overseeing physicians). Because of the exhausting complexity of very sick patients, if you are not among the very sickest (or provide a steady stream of diagnostic conundrums requiring the input and expertise from the top experts), your care will be left in the hands of the residents. This doesn’t mean you won’t get good care, but it introduces some degree of risk.

3. You may be exposed to really bad germs. Drug-resistant bacteria are born in places that use big-gun antibiotics. Again, with more challenging cases and infectious diseases in the patient mix, more antibiotics are used and more drug-resistant bacteria develop. Although academic centers make great efforts not to spread infections, it can happen. And if you do get a hospital-acquired infection, it’s probably going to be a bad one.

4. More providers means more opportunity to make EMR-based medical errors. As I’ve argued in recent blog posts, electronic medical records are error prone for a number of reasons. The more people entering data into your record, the more opportunity for mix ups and confusions. Academic medical centers may boast more specialists and a higher staff to patient ratio, but this is not always a good thing. The fewer the number of providers caring for you (especially nurses), the better you are known to them, and therefore the lower the risk of certain mistakes.

5. More tests and procedures aren’t always a good thing. Academic centers have access to a larger breadth of technology, which means that they are more likely to order more tests and procedures. Imaging studies, biopsies, lab tests, and advanced surgical procedures can provide additional information that can change the course of therapy. But they also have the ability to initiate wild goose chases, further testing, unnecessary anxiety, and additional risk (and expense) to the patient. Judicious use of technology is important, but with less experienced physicians on the team, they are more likely to reflexively order a test than to rely on their clinical experience regarding diagnosis and treatment.

6. Many “moving parts” increase your risk for errors, mix ups, and longer wait times. The larger the hospital, the more chances there are for accidental substitutions, name confusion, and test scheduling conflicts. It may seem improbable that these events still occur (Don’t we have bar codes on wrist bands that have solved this problem? You ask.), but if you’re a physician clicking between electronic medical records of patients with the same last name, no bar code will save you. I myself was a patient in the ER of a large elite academic center once, when the security guards confused me with a volatile psychotic patient previously located in the bay that my stretcher was moved into. They almost got the four-point restraints on before I convinced them to re-check my identity with the nurses. Awkward. Also, if you need an MRI or CT scan at a level 1 trauma center, you could be waiting a long time for it as sicker patients bump you from the schedule.

7. Traveling to a center of excellence means post-acute care services will be harder to arrange. If you are recovering from a serious illness or surgery far away from home, case managers will probably have a harder time connecting with services to help you upon discharge. If you need visiting nurses, home-based therapists, durable medical equipment, or follow up care (either with specialists or primary care physicians) all of that will be more challenging to arrange because the case managers don’t have them in their virtual Rolodex. Because of the complexity of the healthcare system, it takes years of effort for good case managers and discharge planners to streamline the process of getting through to the “right person” at each service provider and providing them with the “correct” insurance information and completed forms and paperwork. If they’re lobbying for you out of state or in a far away county, they will probably end up spending a lot of time on hold, or talking to the wrong person. And when you finally arrive home and the visiting nurse doesn’t show up, or you don’t have your walker after all… you will not be happy.

8. You may be stuck with an enormous, post-hospital price tag. Most people nowadays have insurance that covers care at certain “preferred” facilities at a much lower cost to the patient. If you go “outside of network” you may be responsible for a much higher percentage of your care cost than you bargained for. Before you decide to opt for the big brand name academic medical center for your care or procedure, double check with your insurance provider regarding what your part of the cost will be.

If you (or your loved one) are in the unfortunate position of having a rare, life-threatening, or extremely complicated host of diseases and conditions, then you may have no choice but to go to an academic medical center for care. If you’re like my wealthy patient, though, and can afford what you think are insurance upgrades to provide you with access to the “best care available,” you may discover that better care is actually found closer to home.

In an upcoming post, I’ll describe my experience with hospital characteristics that tend to predict a higher quality of care. You may be surprised to find that there isn’t a whole lot of overlap between my personal measures and what we are led to believe are the important ones. :-)

The Problem With Running Medical Information Through A Digital Intermediary

In my last post I wrote about the communication difficulties caused by electronic medical records systems. The response on Twitter ranged from sentiments including everything from “right on, sister” to “greedy doctors are only complaining about EMRs because of their price tag.” The disconnect between policy wonk’s (and EMR vendor’s) belief in the transformative power of EMRs and exasperated clinician users of these products is jaw-dropping. Physicians are often labeled as obstinate dinosaurs, blocking progress, while policy wonks are considered by physicians to be living in an alternate reality where a mobile phone app could fix all that is wrong with the healthcare system.

Being on the dinosaur side, I thought I’d try a quick experiment/analogy to demonstrate that EMR dissatisfaction is not a mere cost artifact. To show what happens when a digital intermediary runs medical information through a translator, I selected a random paragraph about the epidemiology of aphasias from an article in Medscape. I copied and pasted it into Google translator and then ran it backwards and forwards a few times in different languages. In the end, the original paragraph (exhibit A) became the second paragraph (exhibit B):

Exhibit A:

“Not enough data are available to evaluate differences in the incidence and clinical features of aphasia in men and women. Some studies suggest a lower incidence of aphasia in women because they may have more bilaterality of language function. Differences may also exist in aphasia type, with more women than men developing Wernicke aphasia.”

Exhibit B:

“Prevalence and characteristics of men and women are expected to afasia is not enough information available. If afasia some studies, women work more, not less, because they show that the spoken language. There may be differences in the type of OST, women and men to develop more of a vernikke afasia, more.”

Although the B paragraph bears some resemblance to A, it is nearly impossible to determine its original meaning. This is similar to what happens to medical notes in most current EMRs (except the paragraph would be broken up with lab values and vital signs from the past week or two). If your job were to read hundreds of pages of B-type paragraphs all day, what do you think would happen? Would you enthusiastically adopt this new technology? Or would you give up reading the notes completely? Would you need to spend hours of your day finding “work-arounds” to correct the paragraphs?

And what would you say if the government mandated that you use this new technology or face decreased reimbursement for treating patients? What if you needed to demonstrate “meaningful use” or dependency and integration of the translator into your daily workflow in order to keep your business afloat? What if the scope of the technology were continually expanded to include more and more written information so that everything from lab orders to medication lists to hospital discharges, nursing summaries, and physical therapy notes, etc. were legally required to go through the translator first? And if you pointed out that this was not improving communication but rather introducing new errors, harming patients, and stealing countless hours from direct clinical care, you would be called “change resistant” or “lazy.”

And what if 68,000 new medical codes were added to the translator, so that you couldn’t advance from paragraph to paragraph without selecting the correct code for a disease (such as gout) without reviewing 150 sub-type versions of the code. And then what if you were denied payment for treating a patient with gout because you did not select the correct code within the 150 subtypes? And then multiply that problem by every condition of every patient you ever see.

Clearly, the cost of the EMR is the main reason why physicians are not willing to adopt them without complaint. Good riddance to the 50% of doctors who say they’re going to quit, retire, or reduce their work hours within the next three years. Without physicians to slow down the process of EMR adoption, we could really solve this healthcare crisis. Just add on a few mobile health apps and presto:  we will finally have the quality, affordable, healthcare that Americans deserve.

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