
Some doctors think EHRs are hurting their relationships with patients - rexercises
http://www.pbs.org/newshour/rundown/doctors-think-electronic-health-records-hurting-relationships-patients/
======
davycro
Emergency doctor and hacker here.  The closed systems and lack of support for
interoperability between EHRs upsets me the most because it leads to patient
harm. 

I just had a patient transferred from an outside hospital for abdominal pain
and somehow their CT scan was lost in transit.  Because it was an emergency we
had to CT scan them again which doubled their radiation exposure and their
risk for a kidney injury from the iv contrast.  It was midnight so it would
have taken until business hours to obtain the scans from the hospital. 

Things like this happen almost daily. 

~~~
nwhatt
The problem is not necessarily closed systems or lack of interoperability
support. 

In your situation with CT scan, it sounds like there was no electronic way to
share the digital version of the CT scan.  Furthermore, if there was an
electronic way to share it, your ER where the patient presented would need to
be connected to any and all other facilities they could be transferred to. 

To further complicate matters, and electronic CT scan isn't really EHR
functionality, it goes straight from the CT device to a PACS (picture
archiving and communication system).  There may be integration with the EHR,
and definitely with the RIS (radiology information system), but outside of
those two, you're talking about transferring 100s of MBs to GBs of data to the
other hospital. 

If I ran your hospital IT team (or rather the hospital you're referring people
to) I would prioritize integrating the two.  Duplicate scans cost them money,
and if you have choice over where you refer patients - the integrated hospital
will always be preferred right? 

~~~
robmiller
_it sounds like there was no electronic way to share the digital version of
the CT scan_

Seems unlikely.  A few years ago I was given a CD-ROM of the scan of my jaw and
was able to download a free DICOM viewer to look at it.  These things seem to
be standardized. 

Wasn't really excited to take that much dose to my head but at least I have
the souvenir of a 3D view of my jaw...

~~~
nwhatt
By electronic I meant over a network - a burnt CD may have well been the media
that got lost in OP's situation. 

The problem is that the digital scan is isolated to his ER's network, and
without a business relationship between the two parties, a CD is the only way
to transmit the data. 

~~~
ch4s3
This is pretty key and why HIEs exist.  They're a hackish solution though.  Some
sort of national data exchange would be useful. 

------
athenot
> _" He says EHRs now function primarily as documentation for billing and
> quality reporting rather than as an aid to doctors."_ 

This is the money quote right there.  EHRs are purchased by hospital
administrators, the people who are worried about cost and compliance.  They are
the ones who get to dictate the features to the EHR vendor in the selection
process.  Yes clinical staff is consulted but usability is only ever a
consideration when a high-enough ranking doctor goes on a rant about it. 

~~~
flldikeud39
I'm a healthcare provider and have worked in a various EHR settings. 

I have mixed feelings about all of this, and think the problem with EHRs isn't
really the EHRs, it's the systemic problems underlying the EHRs.  The EHRs are
just a tangible way to vent about them. 

First, the way these EHRs were rolled out, under federal mandate, was a
fucking fiasco.  I am definitely _not_ anti-government when it comes to
healthcare, but I do not think EHRs should have been mandated.  People forget
that in all of this.  Administrators did not want to purchase them, because
they were huge cost sinks (the rollout of one EHR at a hospital my wife works
at was 2 _billion_ dollars over what they initially estimated it to be).  So,
you have these systems which weren't purchased because they were appealing
solutions, or cost effective, but because the hospitals had to to avoid losing
reimbursements.  This led to systems being rushed early, without adequate
hardening, and all sorts of things.  Before EHRs, records were done in-house by
people who were highly trained in this area.  My guess is that if markets had
been allowed to progress naturally, you would have seen more in-house open-
source implementations that would have happened more gradually, at much lower
cost, and with more back-and-forth with providers. 

Second, I'm a little tired of griping from physicians about having to do
paperwork.  Sorry if this comes across as hostile, but a lot of it is
narcissistic bullshit, frankly.  Records in high-stakes settings is not just
about documentation, it's about checks, and making sure you're following
protocol.  Studies have shown this increases safety.  We all have to do it. 
Someone asked about scribes, but wait until some lawsuit happens because of
ambiguity about whose responsibility it was when some instruction or note was
done incorrectly.  This way, it's ultimately the provider's responsibility,
coming directly from them.  And yes, you can still do transcription for lengthy
notes.  I know this because I've done it.  One of the elephants in the room when
it comes to healthcare costs is that there's too much top-down authority, too
much monopoly, too little competition in provider models, and people feed into
this when they start going down the route of suggesting it's too much to ask
physicians to be responsible for their own damn communication with the rest of
the providers in healthcare. 

Finally, going back to my original point: the real problem in a lot of cases
isn't the EHRs, it's the business-model administrative hierarchy that's taking
over all sorts of fields.  Regardless of whether or not this should be the
case, physicians want to be in charge, to have autonomy and authority, and
suddenly they're finding themselves being treated like widgets in a vast
healthcare machine that benefits administration primarily.  They have to use
some system they didn't approve of, and they realize that the decisions in
some sense aren't coming from them, they're being told what to do by
administration.  So rather than feeling like they're the top dog at the
hospital, they're feeling like cubicle workers. _ That 's_ what I suspect this
is mostly about, not the time with patients, or whatever the hell the
complaint du jour is.  Note that on this point I sympathize with them--this
administrative hierarchical model that's squeezing workers, whether it be
healthcare, or IT, or education, or whatever, is fundamentally flawed.  It's
just new to physicians, or something they didn't think they'd have to deal
with. 

This is my little tangential rant, but I'm sick of healthcare discussions in
congress being so focused on costs, and not on deregulating healthcare and
increasing transparency.  There needs to be less of this kind of EHR red tape,
more use of EHRs that is driven by their utility, more competition among
provider models, greater consumer access to drugs and healthcare options (and
I don't mean by giving them more money, I mean by letting them do whatever the
hell they want), and more transparency about costs.  Right now, we have a model
where you have an extremely small number of people telling everyone else--
including different types of providers, as well as consumers--what they can
and cannot do with their own healthcare decisions, and billing them without
them even knowing or agreeing to the cost of a service.  Imagine if the
government said that only accountants they approve of, with doctoral level
finance degrees, could do your taxes, and that those accountants could charge
whatever they want without telling you the cost ahead of time.  People would be
in an uproar.  We spend all this time assuming that our healthcare system
should basically stay as it is, but that we should reorganize how we pay for
things, when the discussion should be about both. 

~~~
lbhnact
>>It's just new to physicians, or something they didn't think they'd have to
deal with. 

Bingo. 

~~~
xxSparkleSxx
I worked under a lot of physicians and I have a deal of respect for most of
them, but yea I agree also. 

I was in an administrative heavy medical lab and most attempts to streamline
processes were met with a lot of backlash from the doctors.  My director was
told by several of them that he was "undermining and ruining medicine." 

------
Insanity
I work on an EHR.  I work in a hospital on an EHR that is used in a network of
about 20 hospitals.  A frequent complaint I tend to hear is that the doctors
just want to be busy with their patient and not with the software.  We try to
make the software as easy to use as possible, but it is still slower than them
just working on paper for many things (like sharing notes quickly between them
and their assistants). 

On the other hand, I do think that an EHR can be a good thing.  Because we work
closely with the doctors we can tweak things to their liking.  Some departments
spent a great deal more time on tweaking the software (mostly younger doctors)
and that pays off for them.  They lose less time with the software and the
software becomes an aid for them - as it should be. 

It does not happen in every department of all of the 20 something hospitals,
but it _can_ be good. 

From what I have seen in this industry - the worst thing you can do as a
hospital is buy an EHR package by a company that is not working closely with
others in the medical field.  You need communication between the departments
and the engineers, and a short release-cycle surely helps. 

~~~
apathy
Serious question: does your company have a clause in the service contract that
forbids disclosing, documenting, or photographing potentially catastrophic
bugs in the software? 

Aka do you work for Epic

------
throwthisawayt
My partner is a doctor who works at one the top medical systems in America. 
The EHR system she works is atrocious.  Last time she asked me to look at it to
help figure out how to print an image and I stared at this 90s era windows app
that looked like the pied piper interface.  I gave up after 15 minutes and we
ended up screenshoting the image.  Taleo felt like it had a better UX than it. 

I can't believe we let some of best doctors in the country waste hours each
day fighting with terrible software instead of treating patients.  My partner
spends more time trying to figure out the EHR than she does treating patients. 

------
Johnny555
AS a patient, I like Kaiser's EHR system -- the doctor talks to me, then
pauses as he documents on the computer from time to time - he doesn't type
while we talk.  That doesn't seem noticeably worse than him staring at his
clipboard while I'm talking with him. 

But the part I really like is that I have access to most test results online. 

And since Kaiser is a self-contained HMO and doesn't generally do referrals
outside of their system, interoperability isn't really an issue -- when I get
referred to a Kaiser specialist or move to a new area and start seeing a new
doctor, I know they'll have access to my records. 

In a previous system, I had to see a specialist, and though they requested
that my original doctor transfer all records, not all of the records were sent
and I ended up having to reschedule an appointment so I could pick up the
missing records and take with with me. 

------
hyperion2010
Last time I went to see the optometrist (who keeps and all paper office) he
told that he has started to see a huge uptick in fraud. 

How did he know?  He started seeing records from certain docs where they did
the full workup on every single patient.  There is no way they could do this, a
full workup takes between 5 and 7 hours (he said). 

So what was happening?  Someone at these offices had filled out the 'full
workup' form for their EHRs and then discovered that they now literally had a
button that would print money (paid out by insurance companies). 

If you give someone a tool that lets them print money at the click of a button
even if it means they didn't actually do all the tests to fill it in they are
going to click it. 

~~~
Johnny555
Do you need EHR's to do this?  Spending 30 minutes filling out paperwork
documenting a fake 7 hours of work sounds like it's still profitable. 

~~~
hyperion2010
Most offices don't have someone with 30 minutes of their day to spare (per
patient!),  so if they are doing this they basically need someone dedicated to
the fraud.  Now it is 30 minute time cost up front and then they just select it
from the dropdown box. 

------
ortusdux
The only times I've seen EHR's work well is when a 2nd person is at the
computer typing and the doctor sits with the patient. 

~~~
xoail
Yes this is a good option but an expensive one. 

------
koolba
For situations like this I wonder if it'd be easier/cheaper to hire a scribe
to shadow the doctor.  Compared to the doctor's salary, the cost of the scribe
would be a rounding error.  The doctor could scribble illegible notes or maybe
take no notes at all, and the scribe could type up the details (either on the
spot or after the fact). 

~~~
markolschesky
That's actually pretty common, especially for older physicians or high-volume
specialists.  There are also some companies working on solutions to automate
this using in-room speech recognition technologies like
[https://iscribes.co/](https://iscribes.co/). 

------
xoail
I am seeing this issue 2nd hand and I totally get it.  My aunt runs a practice
and her time with the patients dropped significantly.  She is also unable to
see as many patients as she used to before the mandate. 

While I've built few nifty tools (chrome extensions and macros) for her to
simplify some of the cumbersome tasks, I am envisioning and planning to build
a whole new EHR solution from scratch that puts doctors first, as my side
project.  It's a daunting task and requires expert domain knowledge.  Hoping to
get an MVP by end of year. 

~~~
CabSauce
Please build it around a standard (FHIR). 

~~~
xoail
Yes, this is so important and yet I see many EHR companies relax on it since
its not heavily mandated. 

------
Powerofmene
I agree with this.  Over the past five to six years I have taken my aging
parents to many physician appointments.  In the past two years I have seen time
spent with physicians expand from five to seven minutes to thirty to thirty
five minutes.  Less physical exams and more typing, typing and typing. 

As a result when you need an appointment what you hear is that nothing is
available for three to five days.  Numerous times I was unable to get my Dad in
for over a week when he needed to be seen.  Sometimes progress is not progress
for everyone. 

~~~
binarymax
Anecdotal and varies by physician and care center.  My folks can get booked and
seen quickly and efficiently. 

I should add that while the extra data capture may now seem like an issue,
when federated access is better supported it will be a boon to healthcare. 

Aside, since when does PBS write such clickbait?  The article clearly gives
advantages and drawbacks with the current system compared to old.  Why not give
a professional quality title? 

~~~
Powerofmene
Yes it is anecdotal but I was giving my perspective based on the last couple
of years of taking my parents to their physician appointments.  Given that we
have long-standing relationships with our doctors they have shared their
displeasure with the new systems and how it is resulting in longer wait times
to get appointments.  We have repeatedly experienced this.  I know many
individuals who are not and find that doctors offices who are not accepting
new Medicare patients are experiencing this less than those that are still
accepting new patients. 

It is likely that these issues are also geographical in nature as some areas
are not experiencing the physician shortages or patient loads that other areas
and physicians are experiencing. 

------
apathy
More interesting would be if anyone can find a physician who actually
"appreciates" EHRs.  I watched a few with 50+ years in practice decide to
retire upon Epic rollout. 

EHRs are a farce.  They've made a few people very wealthy at the cost of
widespread misery for patients and doctors. 

~~~
shishy
Sorry, I'm a little confused by your comment.  You saw a few physicians with
50+ years in practice retire upon the Epic rollout?  Maybe they were of old age
and near retirement? 

And also, how does that lead to your conclusion that they are a "farce"?  Do
you mean to suggest that we would be better off without EHRs, or do you
specifically have issue with the implementation of EHRs as is right now? 

I'm surprised by you calling them a "farce" and causing "widespread misery for
patients and doctors" because my understanding was that the clinical data
collected by EHRs permitted improvements in the quality and delivery of care
for patients within an institution. 

I will admit that - as mentioned elsewhere in these comments - lack of
interoperability is a huge issue which drastically reduces the effectiveness
of EHRs. 

But even though it isn't a perfect system -- 1) It is an improvement over the
previous form of paper records, and 2) The industry is iteratively moving to
resolve these issues. 

There are a lot of reasons for why these problems exist such as misaligned
incentives, etc.  but we have been trying to address this through both policy
(e.g. the rise of accountable care organizations and how the ACA experimented
with physician reimbursements).  There also exist middleware solutions that I
believe would help ensure that this data is not silo'd, and in doing so
improve interoperability. 

Maybe I'm just misunderstanding something but if I am, could someone please
point it out?  I'm not saying that EHRs are perfect -- they have a way to go
(both in UX design/interoperability).  But, they were a step in the right
direction and I am not convinced that they are as bad as you claim they are
(though I recognize their limitations).  What am I missing? 

EDIT:

I've also heard from physicians and patients that because EHRs easily allow a
doctor to read up on a patient's notes from their previous visits, it can
actually improve their relationship because the doctor can go into the room
for subsequent visits knowing something (or in some cases, everything) about
the patient and speak to them with that information in mind. 

~~~
cepp
> _But even though it isn 't a perfect system -- 1) It is an improvement over
> the previous form of paper records, and 2) The industry is iteratively
> moving to resolve these issues._ 

 __NOTE __: My comments are only applicable to the US medical industry. 

This statement highlights your lack of knowledge about the general EHR/EMR
landscape and current implementations.  As someone that works parallel to a
hospital operation, I both know and interface with people that have to use
them on a daily basis and this could not be further from the truth. 

EMRs have helped to collect and make more data accessible, this is true, but
they are not necessarily an improvement over the previous form of paper
records.  In most cases, they are simply a different representation of the same
data.  Take EPIC for example wherein you can search for a patients name but
then you are provided with the digital representation of an analogue patient
folder and/or chart.  I think that most of the people on HN would have their
opinion of the medical software landscape changed if they were ever granted
the opportunity to use most of the current implementations for only a couple
of minutes...

It is also not true that the "industry is iteratively moving to resolve these
issues".  I was most put aback about 2 years ago when I heard that while every
hospital may have EPIC, Cern, etc installations, that none of them are
universal.  Every hospital will have a customised EHR/MER installation, and
therefore custom templates for each doctor, or unit.  This means that the
installations are almost _never_ updated, or allowed to have new features
introduced.  In most cases, a patch, or update will require a field tech being
sent from the providing company to the hospital where he will work with the
onsite customized installation to complete the work. 

All in all, it is true that there are people in the field trying to push
medical technology forward.  Take PatientBank, Sprig, Stitch, etc as evidence
that this happening.  But what is certainly not true is that the incumbents are
pushing to make major changes.  Additionally, the regulations with regard to
medical software, as well as the legal incentives make it very, very difficult
to develop a product, let alone to bring it to market. 

~~~
shishy
Thanks for your response!  Most of my knowledge isn't personal experience, it's
from speaking with other people and I will admit it isn't super comprehensive. 

I know that there is a distinction to be made from EMRs and EHRs right? ( I
thought EMR was the electronic version of the old paper medical record, while
EHR was designed to create a more longitudinal view of the patient's care). 

Yes I did know that though two hospitals with EPIC's system will still face
interoperability issues due to varying data dictionaries, but I didn't
consider the difficulty in updating features, etc. 

I agree and recognize that the incumbents are not pushing to make major
changes (after all, they don't have strong incentive to, right?).  But I did
notice companies like RedoxEngine which provide a layer of abstraction to
address interoperability issues for health tech startups.  And also projects
like this which are moving to slowly consolidate rather than silo data:
[http://hospital-
zsfg.medicine.ucsf.edu/research/homerun.html](http://hospital-
zsfg.medicine.ucsf.edu/research/homerun.html)

Anyway I will dig more into it to inform myself -- appreciate your response. 

------
portmanteaufu
EHR = Electronic Health Records

------
twobyfour
Were global (or at least nationwide) technical standards and specifications
for data exchange protocols never defined as part of this mandate? 

~~~
lbhnact
No they were not.  The quote, by David Blumenthal who designed the HITECH
legistlation said this:

"Before you can create interoperability, you have to create operability"[1]

I'll leave it to you to decide whether this was a wise philosophy to underpin
a major national IT project. 

[1][http://www.healthcareitnews.com/news/blumenthal-look-
stage-1...](http://www.healthcareitnews.com/news/blumenthal-look-
stage-1-meaningful-use-upshot-next-winter)

~~~
dragonwriter
It seems to be the exact _opposite_ philosophy that HIPAA originally took in
the effort to get financial/administrative transactions to electronic formats,
which was essentially that mandating interoperability would drive mainstream
use. 

------
Skeletor
This is the kind of thing that we are trying to fix at drchrono.  I think
legacy EMR interfaces that are heavily reliant on keyboard/mouse interfaces
are too distracting. 

Mobility (iPad's for drchrono) are just starting to make a bigger impact on
the market and I think over the next 5 years 80% of providers in the US will
be using a mobile interface (probably an iPad) and not touching a
keyboard/mouse while a patient is in the room. 

~~~
walshemj
how do you get round the sterility cleaning requirements I the UK all the pc's
I see the doctors and ward staff using have special wipe clean keyboards etc>

~~~
Skeletor
[http://www.wikihow.com/Clean-Your-iPad](http://www.wikihow.com/Clean-Your-
iPad)

[https://discussions.apple.com/thread/4383886?start=0&tstart=...](https://discussions.apple.com/thread/4383886?start=0&tstart=0)

I clean my personal iPhone/iPad once every few months.  I think it's much
easier and more possible to sterilize a glass/metal ipad than a keyboard
(especially for onboarding of patients in a waiting room.) 

------
kazinator
If your doc is typing away and looking at the screen, it shows lack of
preparation.  He or she should have reviewed those records ahead of the
appointment.  Nothing wrong with those records being electronic. 

~~~
pg_bot
I don't think you understand the amount of information overload that comes
with medical records. 

A typical medical record can contain more than 100 pages of documentation. 
I've seen records that span more than 1500 pages. 

While most medical records are electronic, systems do not interoperate with
one another.  So, you are forced to type in relevant information from a fax
into your EHR system. 

Most of the pain comes with documentation necessary for dealing with billing
and insurance.  In fact most of the language is super vague so that you can
cover your ass if someone tries to sue you. 

Disclosure: I run a start up that is working on solving a lot of these
problems. 

~~~
kazinator
> _I 've seen records that span more than 1500 pages_

That must be someone who goes to doctors as a hobby. 

~~~
recursive
Here's a data collection form for one procedure.  It's 25 pages. 
[http://www.sts.org/sites/default/files/documents/STSAdultCVD...](http://www.sts.org/sites/default/files/documents/STSAdultCVDataCollectionFormV2_9_NonAnnotated.pdf)

