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More Unintended Consequences Of Digital Data: How An EMR Gave My Patient Syphilis

I used to be a big believer in the transformative power of digital data in medicine. In fact, I devoted the past decade of my life to assisting the “movement” towards better record keeping and shared data. It seemed intuitive that breaking down the information silos in healthcare would be the first logical step in establishing price transparency, promoting evidence-based practices, and empowering patients to become more engaged in their care decisions. Unfortunately I was very wrong.

Having now worked with a multitude of electronic medical records systems at hospitals around the country, one thing is certain: they are doing more harm than good. I’m not sure that this will change “once we get the bugs out” because the fundamental flaw is that electronic medical records require data entry and intelligent curation of information, and that becomes an enormous time-suck for physicians. It forces us away from human interaction, thus reducing our patients’ chances of getting a correct diagnosis and sensible treatment plan.

How bad is it? The reality on the ground is that most hospitals are struggling enormously with EMR implementation. There are large gaps in the technology’s ability to handle information transfer, resulting in increased costs in the hundreds of millions of dollars per small hospital system, not to mention the tragically hilarious errors that are introduced into patient records at break neck pace.

At one hospital, the process for discharging a patient requires that the physician type all the discharge summary information into the EMR and then read it into a dictation system so that it can be transcribed by a team in India (cheaper than US transcription service) and returned to the hospital in another part of the EMR. The physician then needs to go into the new document and remove all the typos and errant formatting so that it resembles their original discharge summary note. In one of my recent notes the Indian transcriptionist misheard my word for “hydrocephalus” and simply entered “syphilis” as the patient’s chief diagnosis. If I hadn’t caught the error with a thorough reading of my reformatted note, who knows how long this inaccurate diagnosis would have followed the poor patient throughout her lifetime of hospital care?

Another hospital has an entire wing of its main building devoted to an IT team. I accidentally discovered their “Star Trek” facility on my way to radiology. Situated in a dark room surrounded by enough flat panel monitors to put a national cable network to shame, about 40 young tech support engineers were furiously working to keep the EMR from crashing on a daily basis – an event which halts all order processing from the ER to the ICU. Ominous reports of the EMR’s instability were piped over the entire hospital PA system, warning staff when they could expect screen freezes and data entry blockages. Doctors and nurses scurried to enter their orders and complete documentation during pauses in the network overhaul. It was like a scene from a futuristic movie where humans are harnessed for work by a centralized computer nexus.

At yet another hospital, EMR-required data entry fields regularly interrupt patient throughput. For example, a patient could not be given their discharge prescriptions without the physician indicating (in the EMR) whether each of them is a tablet or a capsule. As patients and their family members stand by the nursing desk, eager to be discharged home, their physician is furiously reviewing their OTC laxative prescriptions trying to click the correct box so that the computer will allow the transfer of the entire prescription list to the designated pharmacy. When I asked about the insanity of this practice, a helpful IT hospital specialist explained that the “capsule vs tablet” field was required by Allscripts in order to meet interoperability requirements with our hospital’s EMR. This one field requirement probably resulted in hundreds of extra hours of physician time per day throughout the hospital system, without any enhancement in patient care or safety.

For those of you EMR evangelists in Washington, I’d encourage you to take a long, cold look at what’s happening to healthcare on the ground because of these digital data initiatives. My initial enthusiasm has turned to exasperation and near despondency as I spend my days as a copy editor for an Indian transcription service, trying to prevent patients from being labeled as syphilitics while worrying about whether or not the medicine they’re taking is classified as a tablet or a capsule in a system where I may not be able to enter any orders at all if the central tech command is fixing software instability in the Star Trek room.

Paralyzed Man Wants To Know: “What’s Your Excuse?”

I have meet several amazing people at my new job.  Here is one of them:  Richard Vaughn (photo credit).  The poster isn’t accurate any longer, the 12 should read 20.

Richard is the IT guy at my work place.  He broke his back at age 17.  This hasn’t kept him from having a full life.

……Shortly after graduation as a 17 year old, a severe accident – a fall of roughly 85 feet from a scaffolding – left me paralyzed and in a wheelchair. This was in the early 1970s. It was suggested that I enter one of several “special schools” for the handicapped. There, I was told, I might learn a vocation and become a “contributing member of society.” Read more »

*This blog post was originally published at Suture for a Living*

“E-Visits” With Patients: For Greedy Doctors Or Not?

Dr. Wes (a cardiology blogger whom all should read) wrote a very compelling post about technology and the bondage it can create for doctors:

The devaluation of doctors’ time continues unabated.

As we move into our new era of health care delivery with millions more needing physician time (and other health care provider’s time, for that matter) –- we’re seeing a powerful force emerge –- a subtle marketing of limitless physician availability facilitated by the advance of the electronic medical record, social media, and smartphones.

Doctors, you see, must be always present, always available, always giving.

These sound like dire words, but the degree to which it has resonated around the Web among doctors is telling. Read more »

*This blog post was originally published at Musings of a Distractible Mind*

Patient Participation In EMRs Can Improve Efficiency

Our office has been on Electronic Medical Records (EMR) for nearly thirteen years.  We see a high volume of patients, keep our overhead down, and are able to be quite successful financially.  All of the “EMR is impossible” and “EMR makes things worse” stuff you read around the web are disproved quickly with a step into our office.  We implemented EMR successfully in a private practice setting without help from an economic stimulus, a hospital system, or a magic wand.

Not that it was easy; we went through many years of struggle to get to where we are today.  We struggled mainly because we were exploring unknown territory.  We had very few other successful EMR implementations to learn from.  We used slow computers and programming developed in the pre-Internet era.  We made huge mistakes and struggled at times to make our monthly budget.

But we did it, and practices implementing now can learn from my and others’ success.  Probably the main lesson we learned is to put office function ahead of implementation.  Since we are a business, we must stay profitable while implementing.  Since we are practicing medicine, we must never compromise quality in the process.  This meant that we implemented over time, focusing on parts that would either improve our process or at least not bring us down.

Now we are at the position I thought might never come: survival is no longer in question, so we can dream.  We don’t have to act defensively, we can push the envelope.  We can afford to ask the question: “How can we build the best medical experience for our patients?”  We can imagine a destination and actually attempt to get there.

The ideal destination is one in which our patients’ care is improved by maximizing efficiency on our end.  Obviously I don’t want to make things harder for our practice, I want to make things easier.  But the goal of care is ultimately centered on the patient, not us.  So is there a way to accomplish both goals?  I think there is, and I think that our EMR is the tool that makes it possible.

Here are our goals in the process:

  • Simplify how things are done
  • Always have the right information available
  • Make communication clear and easy
  • Achieve the highest quality possible

I’m sure some think this is just idealism and can’t happen in reality.  I agree and disagree.  No system can be perfect, but the current healthcare system is so inefficient and ineffective that huge gains can be made.  The best way to show that is to get down to specifics.  Here is where our practice is heading:


The thing that takes the most time away from actual patient care is documentation.  Doctors are paid by the volume of documentation, not its quality.  Still, the main purpose of a record is to accurately know what is going on with the person facing you in the exam room.  Unfortunately, the patient is continually changing, so some information is only accurate for a short time.  Has the patient seen a specialist or been in the hospital?  Have the medications been changed, or just not taken?  Have they changed jobs, quit smoking, or gotten married?  Did their sister just get diagnosed with cancer?  The task of keeping this information up to date is extremely difficult.

Patients are the ones who know these things best, but they are only passive participants in the process.  To keep the record accurate, I must ask them all the right questions on a regular basis.  This cuts into time that should be devoted to care.  So why can’t the patients be allowed to maintain this part of the record?  Why shouldn’t they have access to parts of their record and the ability to correct errors?  Here is how we see this happening:

  • Certain parts of the record should be available for patients to review online.  Basic demographics, medications and allergies, family history, and lifestyle information is a good start.  If something new has happened, the patient can either update this information directly (like marital or smoking status) or notify the office of changes (like medication lists).
  • If the patient doesn’t update it online, then they can do so when they come into the office (while sitting in the waiting room).  Some people will undoubtedly not want to do this, but a significant percent will, decreasing the workload on the office while maximizing the quality of information.
  • Patients should be able to communicate important information to the office online.  If they go to the ER or see a specialist, if their blood pressure or sugars are high, they should be able to send that information directly to the physician.

Another area of potential gain is the gathering of information for a visit.  When a person comes to the office, they have to answer a series of questions related to the visit:

  • what are the symptoms the are having?
  • Are there any other symptoms?
  • How have they been since the last visit?

Gathering this information is essential, but it is one of the main causes of delays.  Here is how we want to employ technology to improve this process:

  • Put kiosks in our waiting room where patients can provide information, such as:
    • History of their present illness.  If they are sick, then what are the symptoms and how long have they gone on?
    • Review of systems.  What other things are going on in their health?
    • Medication and demographic review (if not done already online).
  • If patients fill out information online before coming to the office, the staff will bring them to see the doctor immediately (or at least as soon as possible).

Even 50% participation by patients in this process will have a huge impact on our office workflow.  The end result is a win-win: the patient is seen sooner, the information is more accurate, and the workload of the staff is reduced.  Will there be problems?  There always are; but the advent of ATM machines, airport kiosks, and online shopping are a few examples of process automation that have greatly improved the customer experience.  Why should medicine be different?

I am going to stop here, as I don’t want to lose you (if you haven’t already whacked the keyboard with your forehead).  Hopefully you can see that the use of technology applied smartly can help patients and medical offices at the same time.

And this is just the start.

**This post was published originally at Musings of a Distractible Mind blog.**

Electronic Medical Records: Advice For Physicians

Electronic Medical Records are coming.  The economic stimulus bill (furious spinning kittens notwithstanding) assured this.

Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.

Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.

(From Fierce Health IT)

There will be even more money for implementation.  We look forward to our checks (and are not counting on them yet).

Now it is time for the flies to start gathering.  Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in.  Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares.  It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.

Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam.  It’s like saying “easy solution to the Mideast unrest,”  “obvious way to bring world peace,” or “makes exercise easy and fun.”

Run away quickly when you hear this type of thing.

Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort.  It’s not impossible to become a doctor, but it isn’t easy.  With EMR adoption, the most important factor in success is the implementation process.  A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder.  A well implemented EMR doesn’t just function, it improves quality and profitability.

How do I know?  Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians.  EMR allows us to practice good medicine in a manner that is much more efficient.

So how’s a doc to know who to trust?  What product should he/she buy and whose advice about implementation should they follow?  There are many resources out there.  Here are a few I think are especially worthwhile:

  1. Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future.  The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
  2. The American Academy of Family Physicians’ Center for Health Information Technology and the American College of Physicians both have tools to help member physicians decide on an EMR. Your own specialty society may, too.
  3. Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
  4. Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.

The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully.  This office should be as close in make-up to your office as is possible.  You should be able to look at how they do it and see yourself in that situation.  Never buy a product before visiting at least one office like this (no matter how good the sales pitch).  When you visit, make sure you ask them about the implementation process.  How did they do it and how hard was it?

Which EMR do I recommend?  Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around.  You hear raves and horror stories with every product.  Here is some basic advice:

  • Get a solid CCHIT-approved brand that has been around for a while
  • Don’t pay as much attention to price as you do function.  Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
  • Realize you are paying for a company, not just a product.  It is not like buying a car, it is more like having a child or getting married.  REALLY research that side of things.  A good EMR with a bad company behind it should be avoided like the plague.
  • See how connected the user-base is as well.  A solid user group will do much to make up any deficiencies in the product and/or company.

So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning.  That’s OK, because like medical school, the effort put in gives a very worthwhile product.

**This post was originally published at Dr. Rob’s blog, Musings of a Distractible Mind.”

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