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Major Health Organization Stops Forcing Doctors To Adopt New Technology (internalmedicinenews.com)
nbauman writes: The administrator of the Centers for Medicare & Medicaid Services, told an investors' conference that they will be backing off the unpopular requirement that doctors show "meaningful use" of their new computer systems. Andy Slavitt, acting administrator, admitted that "physician burden and frustration levels are real. Programs that are designed to improve often distract. Done poorly, measures are divorced from how physicians practice and add to the cynicism that the people who build these programs just don't get it."
Dr. James L. Madara, CEO of the American Medical Association, agreed that EHRs were having a negative impact on physicians' practices. Many physicians are spending at least two hours each workday using their EHR and may click up to 4,000 times per 8-hour shift, he said. Instead, CMS will reward health care providers for patient outcomes through the merit-based incentive pay systems created by last year's Medicare Access and CHIP Reauthorization Act (MACRA) legislation.CMS is calling on the private sector to create apps and analytic tools that will keep data secure while fostering true and widespread interoperability.
Dr. James L. Madara, CEO of the American Medical Association, agreed that EHRs were having a negative impact on physicians' practices. Many physicians are spending at least two hours each workday using their EHR and may click up to 4,000 times per 8-hour shift, he said. Instead, CMS will reward health care providers for patient outcomes through the merit-based incentive pay systems created by last year's Medicare Access and CHIP Reauthorization Act (MACRA) legislation.CMS is calling on the private sector to create apps and analytic tools that will keep data secure while fostering true and widespread interoperability.
Shouldn't that be CMMS? Or are they really talking about Content Management Systems?
Carte Vitale is working fine.
I spent about a decade doing high-level end-user compute management for a large healthcare organization.
There are two major forces at play.
Doctors just want fancy equipment so they can keep up status.
Doctors are lazy and entitled, and can't be bothered to do anything beneath them.
I've been on countless projects for SSO or (reduced signon, anyway) and context management. I've had to make sure countless pretty-boy doctors could get the new device that the OTHER hospital gave THEIR doctors. It's **all** about physician satisfaction. It's a seller's market, and if you don't give the doctors every last thing they demand they will go to work at the other hospital down the street. Of course, doctors know EVERYTHING, so there's no negotiating with them at any level. Site managers know they're fucked, and we know site managers are fucked, so we bend over and take it.
The context management systems (that keep patients synchronized across multiple clinical apps -- your EMR, or your radiology app, or your bed placement app, or your 10 other non-integrated apps) all suck and are fantastic boondoggles. SSO works for major systems, but unless you're AMAZING and have every last system in Cerner (or whatever you use), your docs will fuck that up too and blame IT.
Whiny bitches, all of 'em.
>> CMS is calling on the private sector to create apps and analytic tools that will keep data secure while fostering true and widespread interoperability.
If they were serious about interoperability, the Feds would go after Epic Systems, GE and every other provider of incompatible and ridiculously expensive health care software first. Interoperability ain't a problem to be solved with the next crappy Fitbit clone...
Which is the only meaningful way to do it.
All of this bullshit about forcing people to use bad software is just pointless. I only wish more organizations would do this.
On more than one occasion I've been pushed to "contribute" to SharePoint or otherwise use a piece of software which in no way actually helps me do my actual job. Because someone was more concerned with showing how a useless piece of software was being adopted than understanding why it's not being adopted.
Yawn, you're going to give me a fucking badge for posting to a forum which nobody is reading and which won't solve my problem, because you stupidly believe "teh soshul networking" is going to solve all your problems, when all it's doing is creating new ones.
And I've seen far too many systems intended to replace something already in use, which clearly are written by people who just don't get it. It's an often ignored dirty little secret that absolutely crappy interfaces don't get people to use the software because you go through far too much garbage to do anything.
I've seen stuff which tried to replace custom software, with well written GUIs, for crap which mapped everything to try to look like a spreadsheet ... and which was utterly un-usable. It was like some moron wrote the software with no consideration for what it was being used for.
Lost at C:>. Found at C.
One of the major problems is people think doctors are just doing checklists, but most of what they do is observe. You're not observing while you're fiddling with your tablet and looking away from the patient. Strangely, having paper is less of a distraction.
Also, it can create HIPPA security issues.
-- Tigger warning: This post may contain tiggers! --
EHRs were having a negative impact on physicians' practices. Many physicians are spending at least two hours each workday using their EHR and may click up to 4,000 times per 8-hour shift, he said. -- Dr. James L. Madara, CEO of the American Medical Association
How does this metric identify a negative impact in any way? If those clicks are keyboard clicks it doesn't even sound high at all. How about something like "doctors among the top 20% of EHR adoption misdiagnosed 10% more often", or something similar? I'm have no idea if pushing adoption of EHRs is beneficial, but based on the metrics Dr. Madara chose to use they don't seem to have any idea either.
-- All that is necessary for the triumph of evil is that good men do nothing. -- Edmund Burke
"Provide an encounter summary within X business days" (X = 3 or 1, depending). A lot of the doctors I know don't even finish documenting the encounter until the weekend, and that includes doctors who work on paper and are certain that they'd be even slower if they had to deal with a computer.
"Beg patients to please log into your portal and download their record and send you messages" Good luck with that, though I heard that the doctors were rioting over requiring 5% of the patients to use their webpage and now they just have to get a single patient to use it.
They've been absolutely huge on "interoperability" but people who have no idea how doctors document are frequenty amazed at how hard it is to share documents electronically. "What you do mean the cardiologist's computer system has no place to store the brain tumor measurements from my neurologist?! How can my neurologist's software not have a place to hold my chest wall thickness measurements made during my cardiologist's echocardiogram?!!?! INTEROPERATE GODDAMMIT!" Every specialty has their own documentation needs and the software is going to address that.
There had been some really good stuff in here. Convincing doctors to submit prescriptions electronically instead of scrawled and submit and receive blood tests electronically so they can be shared, these are good stuff. The problem is after they got everyone to do that, they needed new things to force doctors to do.
EHR systems are a horrible burden on healthcare providers and as they are currently implemented they offer very little of the benefits to the patient that they could. The UI of the EHR system is implemented essentially only for back office use and the provider interface is bolted on as an after thought. It's extremely clear from even a cursory look at the EHR systems that there was little if any thought given to optimize the workflow for the provider. In a given patient appointment, the provider has to click through various functions each of which requires descending 8 levels of menus to click, then wait for the several second delay and back out 8 levels and decent 5 or more levels for the next round. Patient report not being happy that their doctors are staring at a screen the whole appointment, but with the inefficiencies built into the UI it's literally impossible not to. In addition one of the main theoretical benefits of EHR systems that providers can pull up your health history and make decisions based on all of the information doesn't work because the different systems don't really interoperate as they were supposedly required to do. If you see a specialist that's on a different EHR system you either can't actually access the information without sending IT a request for that information and waiting for it to be made available or it will be in some even more horribly inaccessible format such as an image. Instead of wasting time on apps and analytic tools there should be some real teeth implemented into the interoperability requirement. Instead of being paid Billions of dollars to make systems that have only fake compatibility, they should be required to come up with systems that interoperate seamlessly. I'm going to take a bet that if there were some real, serious teeth implemented such as no government payments to the EHR providers anymore, the interoperability problem will suddenly vanish. I'm not a fan of heavy regulation in general, but when the companies have taken Billions to meet a requirement and they have managed to implement it in name only, then it's time to pull out the big guns. Don't get involved in the details of fixing the interoperability unless they fail again after being faced with serious consequences. Thing is they probably won't, the problem isn't really that hard to solve given the amounts of money spent. The companies currently don't want there to be interoperability because the current lock in benefits them. When that benefit is eliminated they'll fix the problem quickly.
Kaiser was doing fine with computerized records 15 years ago and before the Obama stimulus.
The problems I have seen when around nurses and doctors is usually that the computer systems themselves are horribly done, and the software is even worse at that. (a common issue I have heard is "this computers going so slow", or "the networks down")
It is basically the reason there is no paperless office because software and hardware simply isn't as easy to use as paper, nor is it as stable and reliable.
This is even more apparent in medical situations due to the sort of data they manage.
The cost to make a very reliable computer-based system is incredibly higher than paper and cabinets in every department.
Medical systems need to be stupidly reliable so that cost balloons to even higher values than a typical systems installation in even large business.
Until developer start to make programs that mimic how easy it is to use paper, it will never happen any time soon.
There are plenty of great programs for editing all kinds of stuff, but so many of them blow 10 kinds of ass.
Worse yet, most of those are ones done by professionals for large businesses. Half-assed ActiveX crap was one of the worst cases of this. These days it is more half-assed Java, PHP and MySQL.
Good use of tooltips, an easy-to-access help system (the question-mark feature in some programs where you click it, then click an interface item, is the best in that regard), DESCRIPTIVE menu items.
So many programs lack these very basic things.
You shouldn't NEED to do much learning when using an interface.
If you do, you shouldn't need to read some included PDF or some other readme crap, that is distracting and the user might not have a clue how to describe a visual element on the screen. Having to look through pictures of the UI instead of JUST USING THE UI is stupid, all kinds of stupid.
JUST BUILD A HELP SYSTEM.
tl;dr.
If a system isn't intuitive, it is shit.
This is the reason most people hate upgraded systems.
It is the reason WinXP is still a significant OS today despite being over a decade old.
As usual, change for the sake of change pisses everyone off, not just autistic geeks and Luddites.
A lot of health care providers have been moving to newer patient management systems. I have yet to see any nurse, doctor, or anyone else that has to use these systems actually LIKE them. I know two nurses who absolutely HATE the new systems, that doing it on paper and pencil is far quicker, easier, and more efficient than what was put in. Their opinions are echoed across the industry. It's not an age thing, either. These new management systems are trash, and cost millions to implement and install. All it does is factor in our costs going up more and more.
I have been writing clinical software applications since 1983 and have seen a lot. I spent about a year and a half as a Principal Software Engineer at a Meaningful Use vendor. In that time it became quite clear that just about every MU metric can be and is being gamed by hospital administrators to maximize their medicare revenues at no perceptible benefit to (and sometimes to the severe detriment of) the patient. Meaningful use is a farce. It's yet another case of human nature rearing its ugly head: if the people responsible for administering a system can benefit from gaming the system, then the system will be well and truly gamed.
The state university health system that most of my doctors belong to started using EHR software in earnest about 6 or 7 years ago. It amazes me that the designers and developers of EHR software seem like they design stuff that's intentionally frustrating to use. I've seen worse UIs, but they tend to be for things like buzzword-compliant ITIL based service desk ticketing software, or things that are so proprietary that a functional GUI is not something the customers will pay for. Every time I've gone for an appointment, especially when I'm a new patient (even within the same health system,) the first 10 minutes of the appointment is a frustrated doctor asking question after question, followed by 6 keystrokes, 20 clicks, dropdown here, expand button there, etc. etc. etc. It's as if an offshore code factory was handed a spec, coded exactly to that, and no integration work was done to ensure it would be usable -- and I wouldn't be surprised if that was the case. You might say doctors are a pampered, privileged class who are used to having nurses and medical assistants to do all the "work" but from what I've seen the software is a mess. My dermatologist gave me a "tour" when he found out I was an IT guy -- if I were a doctor I'd be running back to the paper charts in a flash.
Contrast this with the industry I work in -- airlines. Yes, it's old, proprietary, ancient, slow dinosaur technology.at the core, but the GUIs are designed for maximum throughput. An experienced reservation agent can do a booking in under a minute without taking their hands off the keyboard, and everything in the application is actually designed to minimize cognitive load. As an example, I've never worked behind the counter on real passengers, but I can sit down in front of the GUI and understand the flow, look stuff up, etc. That's because the reservation system companies do actual time-and-motion studies and watch real people use the product. I highly doubt the EHR companies do this, nor do they have anyone on staff who uses their software regularly.
I've worked with MD's for many years. Yes, they complain about many EHR things...but only when the EHR does not serve them or their patients, but is instead use to make them into secretaries and used as a means to sue them or rate them poorly.
If the purpose of EHR's is to increase the speed of patient care, then great. Most docs LOVE being able to access patient records from home or from the office or from the hospital.
My personal physician had his practice go through THREE different medical records systems in less than two years. It's a waste of his time every time he's got to learn a new system!
If it's to rate doctors, there are much better ways.
BTW, the original article asked about making EHR's more universal or more secure...they can't be both. The more people who can access EHR's, the less secure they will be. If every pharmacist, doctor, nurse, social worker, psychologist, nursing assistant, EMT, etc. can read everyone's EHR, how many people will have secure med records? Answer: close to ZERO.
So which is more important to you, interoperability or security of your medical records?
How about getting doctors to print legibly? When they clear that hurdle, then they can move onto computers.
Look, the truly awful, horribly expensive solutions that lock people into insanely overpriced development projects are truly bad. Federal investigation into this company for ripping people off bad. No question. For the very few hospital systems that had their own home-grown systems, they do and still do okay.
But, the law had a purpose. Not having access to a comprehensive medical records causes injury and death from decisions made without the full record. It's a fairly well researched fact. But, nothing about the current systems address that need in any real way. Frankly, vendors have made claims that are (in my mind) almost criminally false.
It'd be nice to point and say that engineers are programmers are at fault, but if you look at those vendors and the medical informatics field in general, those who make the decisions are often doctors, nurses and other health professionals. The field is littered those who are unhappy with practicing medicine and think they can be software engineers and researchers instead and the result is an unspeakable mess.
The first step is that doctors, nurses, and so on will have to work with software engineers, system analysts, interaction designers and so on as peers. Not as contractors, not as subordinates, but as peers. And there are way too few doctors, etc. that can accept that a set of programmers can have just as much of an impact on the health of our population as they can. For better or for worse. And, yes, sadly, too many engineers have too much hubris and disrespect for how hard the care of other human beings truly is.
And, until we in America accept that access to universal, affordable healthcare is a fundamental right, we won't look far enough past profit to make a difference anyway. So, in the meantime, people will get needlessly hurt, will needlessly suffer and needlessly die.
Let's take the people with the training, the only revenue generators in a practice, and make them enter data. That's a great use of resources. Now let's make them link all their computer systems to the internet and then fuck them when something goes wrong and data leaks to the intra-webs. Then let's change the billing coding system, ICD-10, that adds almost an insane amount of possible diagnosis codes. Yes, that will bring down the cost of health care. Sure, sure it will.
Conservative, mod down for violating
I was onboard with the changes until I hit that one. It is NOT the "only meaningful" - or even a "right" - way.
As with most things involving punishments for undesired behavior, such a system creates unintended consequences.
This one would reward doctors who only accept patients with mild illnesses or hypochondria and punish those who take on patients with severe illnesses. The result would be the sicker you are, the harder it would be to find someone to treat you.
Just as a similar rating system, punishing doctors for "overprescribing" painkillilng medications, has decimated the ranks of pain specialists and led to under-prescription, suffering, and a drastic rise in PTSD (which appears to be prevented by adequate opioid doses in the first week or so after a trauma), this bright idea will lead to increased suffering, disease, and death.
Bantam Dominique roosters crow a four-note song. Once you've heard it as "Happy BIRTHday" you can't NOT hear it that way
I think some of the most useful - and oft overlooked - advances are in records-keeping and information-sharing. Unfortunately, it also seems that in general there is often a poor track-record of security when it comes to keeping such things private, but it's a trade-off.
I'm Canadian, so my experience is going to be different than the U.S, but here I can
a) Go see my doctor's clinic, which recommends an X-ray
b) Go to a hospital, where they read my script but also can get more details on the request/history from my medical log
c) Get the X-ray, which gets stored in the computer system both for my doctor to access nearly immediately, but also potentially for any future physicians/specialists
d) Get a prescription based on the results of the above, and see a pharmacist which checks the current prescription against the records of anything else I may be taking (or known allergies) to prevent dangerous interactions/conflicts
The system isn't perfect, but technology saves a *lot* of time shuffling paperwork between physicians/locations and can save lives by revealing potentially life-threatening drug-interactions or previous medical history/conditions
On the one hand, I understand the frustration if an EHR/EMR isn't working well. Doctors really should not have to deal with that.
On the other hand, there is reality. Vendors won't work on workflow optimization unless they have customers to pay for that and are willing to become actively involved. As in, the customer will call the vendor and point out specifically what is wrong, and how they'd like to see it changed. And if that doesn't work (it doesn't always work, it must be said), then the customer moves to a different company or product. That sends a message to uncooperative vendors. A strong message!
There is a segment of the medical community that is p'eed off because they aren't quite seen with the deference they used to get. Now information is cheap and readily available. The average citizen has a decent education. And medical services are expensive, expensive enough that it's a problem for average citizens.
You saw the result with ICD-10. There was an elaborate game of "Crying Wolf" among the American Medical Association and various retrograde supporters, claiming the sky would fall, medicine would stop, and patients would be hurt or worse. Instead it went ahead with relatively few problems.
Why? It was a political football. And a power grab by the AMA.
The EMRs will get better, it's only a matter of time. So will I defend poorly designed software? Hell no! But I know that this is a temporary situation. And I also know there's a strong will among the least progressive clinicians, to turn back time. And that's not going to happen. The cost of healthcare and footdragging in the medical community has ensured they no longer have control of the public agenda.
Want to have a positive impact? Contact the people responsible for the software. Bend their ear and try to make a difference. That's what moves the world forward, not bitching on social media to millions of people with no power or involvement.