Reining in the EHR Monster

Dr. Lisa Rosenbaum has an excellent piece in the NEJM this week entitled Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine.  In essence a review of Dr. Robert Wachter’s book The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, it deals with the ever increasing intrusion of the digital-industrial medical complex on the practice of medicine.  Bottom line, electronic health records (EHR) in their present form interfere with patient care.

It doesn’t really matter how we got to this point. Many well-meaning people in government, the insurance industry, and the medical software industry have contributed to this mess. Despite good intentions, they have created a broken system.  It’s clear why.  As Dr. Rosenbaum points out, the one key element lacking input into the development of EHR systems has been physicians. What do they know? Clearly those who designed current EHR systems either don’t know or don’t care how doctors actually practice medicine.

There is nothing inherently bad about the concept of electronic health records. There are clear benefits to these systems. The ability to look up medical records online (albeit limited by poor EHR interoperability) is a tremendous advantage over the clumsiness of paper charts. There is no denying that electronic prescribing is a real advance over illegible handwritten prescriptions. EHRs that would be easy, even fun to use can be designed. Doctors are not adverse to technology.  Their noses are as buried in their iPhones as much as anyone’s.  I don’t even think it would be very hard to design a “fun” EHR. Unfortunately there are powerful forces that would resist such a design.

The government and insurance companies want to “play doctor” and tell doctors how to practice medicine through the medium of “meaningful use.”  They need to stop using doctors as guinea pigs in this experiment of enforcing medical practice guidelines via EHRs.  The system of billing based on documentation is also at fault.  EHRs need to shift from documenting for the purpose of billing to documenting for the purpose of medical care. The EHR vendors need to pay attention to the actual workflow of doctors and other health care personnel and emulate that workflow as closely as possible.  Like any good tool, EHRs need to be as transparent as possible. The last thing we as doctors should be doing is paying more attention to our computers than our patients.

A common physician workflow, which I and many of my colleagues used, is as follows. Whether seeing a patient in the office or in the hospital during rounds, there were 3 basic steps: 1) I would review old notes, test results, and other records. 2) I would go see the patient, take a history and do a physical. During this step the patient has my undivided attention.  And 3) write orders and document the visit. The main purpose of the documentation was so I and others could come back later and know what my thoughts and plans were for the patient.  This workflow can be emulated using an EHR, but only if the current excessive documentation burden is lessened.

In an ideal world, medical documentation would be brief and to the point. We don’t live in that world. Per the medical coders, a written note saying “review of systems negative” can’t compete with a screenfull of checkboxes all checked as negative — as if this is somehow more meaningful. A cut and pasted note chock full of details but identical to the note from the patient’s last office visit is more legitimate than a brief “no changes in patient’s complaints, findings, or plan,” even though they are identical in meaning. Brevity is the soul of wit, but apparently not in the EHR world. Somewhere behind the scenes there are coders counting bullet points and government bureaucrats making sure meaningful use checkboxes are checked. Did you review the patient’s allergies? How could anyone know if the ‘allergies-reviewed’ checkbox isn’t checked?

Early versions of Microsoft Word were notorious because of the inclusion of Clippy the paperclip. Clippy would constantly pop up while you were writing with “helpful” hints like “It looks like you are trying to write a letter. Can I help?” The answer was usually a resounding “No, get off my computer,” and mercifully Microsoft euthanized Clippy in later versions of Word. Writers trying to write a novel don’t want some know-it-all computer assistant popping up and offering them suggestions on how to round out characters or improve the plot. They want the computer to get out of their way and just put the words up on the screen that they type. Maybe that’s why George RR Martin still uses ancient no-frills WordStar to write his novels.

Similarly doctors don’t want some transmogrified Clippy-monster lurking in their EHR system telling them what to do. “It looks like you are writing a progress note. Would you like to review the patient’s allergies? Please click this button. And if you click just two more review of system points, your note could be coded as a level 4 visit rather than a level 3. Would you like to embed the lab and Xray results in your note? This will show the coders that you have definitely reviewed these results and could bring your note up to a level 5 visit.” And so on.

EHRs need to get out of the way of both patients and physicians and become unobtrusive. Government needs to stop trying to social engineer the practice of medicine via meaningful use. The EHR should be a tool like a stethoscope or ultrasound. Right now it is a monster sucking the lifeblood from the profession.