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Technology Is Making Doctors Feel Like Glorified Data Entry Clerks (fastcompany.com)
An anonymous reader writes from a report via Fast Company: The average day for a doctor consists of hours of data entry. Since the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 took effect in January of 2011, which incentivized providers to adopt electronic medical records, hospitals have spent millions, sometimes billions, on computer systems that weren't designed to help providers treat patients to begin with. The technology was supposed to reduce inefficiencies, make doctors' lives easier, and improve patient outcomes, but in fact it has done the opposite. "Frankly, the main incentive is to document exhaustively so you cover your ass and get paid," says Jay Parkinson, a New York-based pediatrician and the founder of health-tech startup Sherpa. The systems are flooding doctors with important and utterly meaningless alerts. One of the biggest problems is that the systems have made it very difficult for doctors to share information between one another, which is what the systems were intended to do all along. Why? "Because it doesn't help the bottom line of the biggest medical record vendors or the hospitals to make it easy for patients to change doctors," reports Fast Company. Since it often takes weeks, or months for data to be sent to and from facilities, that, according to Consumers Union staff attorney Dana Mendelsohn, increases the chances of doctors ordering duplicate tests. All of this reduces the time doctors have with their patients. A recent study shows that the average time doctors spend with their patients is about eight minutes and 12% of their time, down from 20% of their time in the late 1980s. "This group is 15 times more likely to burn out than professionals in any other line of work," reports Fast Company. "And much of the research on the topic concludes that 'documentation overload' is a key factor." To help alleviate this pain, medical groups are working to reduce the data-entry burden for doctors, so they can in turn spend more of their time with patients.
My primary card doctor is reasonably young and when I started seeing her, she keyed in notes about treatment plans and such right into the office computer. So I know she's comfortable with computers and that's she's a fast typist.
About two years ago, when she came into the exam room, she was followed by a young person with a laptop whom she introduced as "my scribe!" Her scribe was constantly tapping away at the laptop, taking notes and entering orders and so forth.
I don't honestly know whether this is good, bad, or indifferent, but it certainly is evidence that the burden of data has become so overwhelming that doctors need assistants specifically to help with that.
She works for a gigantic megapractice that is proud of being a Patient Centered Medical Home and an Accountable Care Organization and all that good stuff, so I think they are following current "best practices."
Geezer reminiscence on. When I was a kid, the doctor's office had a big lab, where they had microscopes and hemocytometers and did their own lab work, and a small business office. Now the labs are gone--they send all the lab work out. The business offices occupy a third of the floor space, because they need room for people waiting all day long on hold to talk to insurance companies. And they have to hire scribes to help the doctor with the data entry. Maybe it's progress.
"How to Do Nothing," kids activities, back in print!
I have stage 4 cancer and spend a few hours at the doctor's office every month. The phlebotomists spend a solid minute selecting my record, marking off all the tests, verifying id, insurance, etc. The nurses go down the list of 50 prescriptions I have, asking me if I'm still taking them, even when I say nothing has changed. They're all very polite and nice, but the whole system fails at easy things should be easy, hard things should be do-able design. You can tell that no one who designed the system ever actually performed the tasks at hand (or they were bound by absurd requirements). And all that isn't including the massive bureaucracy of insurance or scheduling that will sink days of your time pressing buttons on your phone trying to talk to an actual person.
In my experience american health care is an inefficient, bureaucratic mess manned by very friendly medical professionals.
Usually because of bad UI. All knowledge has been replaced with codes and it's our job to learn the codes to find anything. ...and tomorrow the codes will change, because fuck you.
Jesus fucking christ, didn't we invent "Search" to solve these problems?
This is the exact 'outcome' you would expect when corporate lobbyists write government policy. Instead of that policy providing the maximum service at the lowest cost, it provides the least service at the maximum cost. That cost being to the end users and not of course the lobbyists funders, for them it is as cheap as possible and hence maximises profits, 100%, 200%, 1,000% unlimited profits and unlimited power. Pretty 'sick' stuff (snark).
Point of sale tech companies should be writing this, a range of confirmed, emphatically confirmed (use big fonts on confirmation with details to ensure readability, really big fonts, mistakes will kill, so confirmation buttons at the end of each sentence, think plane take off check lists), selection through a menu structure with additional comments and possibly a patient screen so they can see what is going on. You really want the doctor inputs to occur as they treat the patient, medium sized touch screen with a readily and cheaply replaceable cover (swap between patients, doctor touches patients, doctor touches screen) and a camera for close ups and photo record, possibly video elements of doctor patient sessions (all suspended on an adjustable arm from the ceiling) with a smaller smart phone styled extension (corder, doctor patient privacy requires a completely wired system) for greater flexibility. A smarter system would have some idea of what it is 'looking' at and recording ie it can recognise parts of the human anatomy arms, eyes, ears etc (helps guide the menu structure, don't let M$ touch this bit, they always fuck this shit right up, no Mr Paperclip fuckups).
Chaos - everything, everywhere, everywhen
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Not everyone operates on a medical system like the weird one in the US....
Hourglass says she knows a kid in Iowa who grows up to be president.
My hospital does this for handwritten progress notes in charts. It's nice. Especially in anesthesia, which has an elegant (if densely-packed) system of record keeping. For years after the VA put everything in a flat-text note syste, their anesthesia records were done on paper and stored as images.
If you want to get a visceral appreciation for the complexity of medical billing today, check out the Medicare Claims Processing Manual.
It almost seems like you can't merely get an administrative assistant, but you need someone with an A.A. in medical billing.
The thing that really left me aghast was the move from ICD 9 to ICD 10 (diagnosis codes and descriptions). Those #$&!!?! policy geniuses completely abandoned the ICD 9 codes and instituted all new ICD 10 codes. There was a big infrastructure around ICD 9. There is plenty of overlap in the codes, so it's a recipe for mass confusion. It's stunning that there was not even any attempt to have even a scintilla of backward compatibility.
It is almost like there are no senior database or programming architects involved in any of these decisions regarding medical IT. From what I've seen, it seems to me that it's purely non-technical policy staff driving this stuff. You have to get senior database and programming and UI architects in some of these decisions to reintroduce some sanity and control over the complexity of the solutions.
So, yeah. I've come through my training early in the era of EMR's and have seen this clusterfrack evolve over nearly a decade and a half. I've worked with more than half a dozen EMR's over the past 15+ years, and have not only not seen anything more than improvements in appearance (because in large institutions and hospitals the paper-pushers that are actually going to approve an EMR can really only go by how it looks, since they rarely truly understand what doctors need from a record system), and I would go as far as to say many EMR's are becoming actively more difficult to work with, demanding more repetitive entry of questionably valuable data, more and more "billing" specific entry, and, as noted above, more and more URGENT ALERTS that only rarely are actually relevant to my patient.
As also noted above, patient interactions have become the absolute smallest fraction of my work. I spend easily 2-3 times the amount of time I spend seeing and talking to patient in documenting those interactions, and new patients can far-to-often take an hour or more to document "adequately" in many EMRs I have had to deal with. I have colleagues that work from 7A to 6-7P, go home, and then after a few hours with their family, they resume "charting" until 10PM, 11PM, or even later. I've even had emails sent after 1AM from colleagues when I know they were in clinic that day, and have clinic the next day. And these are not periods of "unusually heavy utilization" like flu or RSV season, this is their typical clinic. Visit documentation, lab orders, lab confirmations, insurance issues, finding results in the system. It's disgusting that I spend so little time actually BEING A DOCTOR. It's even more disgusting that I'm told the problem is I'm not "using it right," or that I need to "be more efficient with my documentation," but every time I've requested assistance with "using it right" or improving efficiency (god what an infuriating phrase), I've been either blown off or had someone come by to "listen to my concerns" but never actually stayed to OBSERVE practical use, so nothing continued to change.
The core problem is, I have YET to see an EMR designed by people who actually have gotten down-on-the-ground with medical providers. None of these programers have followed us around, have watched the nurses, have shadowed the medical assistants, and so of course none of them can really meet our needs! Can you imagine the absolute HELL that would be raised if this is how coding was done, for example, in the aerospace industry? If the guy responsible for setting up the pilot's computer never set foot in a cockpit?
I've struggled with bad and worse EMRs (on top of other issues admittedly), and personally I've partially given up. I've left my full-time sub-specialty practice. I'm considering part-time now, though even that would be close to 40 hours a week. Frankly I'm tempted to leave medicine altogether, though I really don't want to give up patient care. As corny as it probably sounds to the /. crowd, I *love* (most of) my patients. I loved being able to help people figure out how to live with chronic issues, helping them get healthy and stay that way, talking with families about their fears and helping them come to terms with major diagnoses or deal with worse... It's an honor and a privilege to have been given this much TRUST by people, and I've done my damnedest to be worthy of that privilege. However, modern medicine has become so obsessed with documentation, and EMRs have become the worst reflection of this documentation, that medicine is becoming ever more toxic a field to work in.
TLDR version; EMRs are not user friendly (they are fairly Admin and billing friendly, though), they are not getting better, and they (in my humble experience) are demanding more and more time for less and less benefit, and in many ways they have become a problem WORSE than the problem they were intended to solve. This is not a "doctors hate technology" problem, this is a "doctors are not being given
They have the wrong article linked above. This is the right one: http://www.fastcompany.com/3061860/the-future-of-work/how-technology-is-making-doctors-hate-their-jobs
Burn down the medical schools and start over. As a society, we need to get back in touch with the basic fundamentals of what constitutes healing and caring for one another. What the modern medical establishment has morphed into is an abomination.
Its excellent news that more and more people are able to bypass the medical establishment in various ways and that the remaining vestiges of it have been reduced to frivolities like data entry. Hopefully it will become completely obsolete before long.
Also, you need your tax prepare only once a year, while doctors get a steady stream of patients. In reality you pay to the healthcare industry probably approximately $20,000 in the form of your family insurance premiums and copays. Tax accountant can only get from you your $300 per year.
The human body doesn't change much in a year, nor does medical technology. The IT spending a doctor has to spend isn't so much to improve patient care so much as to align with Federal and insurance company requirements.
IMHO, the tax dude has to deal with bigger changes year over year than my doctor does. My doctor is dealing with insurance and the feds, which have nothing to do with my health. My tax dude is dealing with dumass changes to the tax law. Odds are, if something is really wrong with me then the changes the doctors have to deal with won't affect anything other than who pays for them, or which department of who pays for them. OTOH, having a tax dude who can save me $1k/yr (which my guy has done for 12 years) affects my life more than an insurance classification.
My point is, doctors can no longer view patient outcome as their #1 goal. The goals now are:
1) don't get sued
2) if you get sued prove you did every test imaginable
3) If you don't get sued ensure you billed properly
4) Hope for the best in getting paid
5) Patient? Who? Oh yeah, hope they got fixed.
the constant battles on the part of doctors to get paid by insurance companies who's single goal is to not pay. In no other part of my life are my goals (getting care) and the service provider's goals (not paying for that care) so diametrically opposed. I've got family members with nasty health complications from easily treatable problems that were let go because the doctor didn't want to order tests in case they came back negative. If a test comes back negative the doctors never get paid.
Come to think of it I see this in one other place. B2B transactions. In so many of them business A won't pay the invoice for business B until A needs B's services again. I read somewhere Don Trump is famous for that, but having worked for small businesses it's so common he could just be going with the flow.
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Here is the root problem: America spends 18% of GDP on healthcare. Other developed countries spend 6-9%, yet mostly have better health outcomes. So if we become as efficient as them, 1/2 to 2/3rds of healthcare workers will be redundant. What interest do they have in destroying their own jobs? Our healthcare system will not fix itself from the inside. They have absolutely no incentive to do that.
It depends on their tech setup. One heathcare provider has a workstation in every room, and it takes the doctor about 1 minute to review patient records and a couple more minutes to update it after the exam is over. Another heathcare provider takes notes and transfers them all at the end of the day. Yet another still uses paperwork and is very much not organised.
It depends on their tech setup. One heathcare provider has a workstation in every room, and it takes the doctor about 1 minute to review patient records and a couple more minutes to update it after the exam is over. Another heathcare provider takes notes and transfers them all at the end of the day. Yet another still uses paperwork and is very much not organised.
I don't want to use explictives, but they are warranted to the most extreme degree possible.
This 1 minute talk, it takes that long to login..if the system is polite, then to open the chart, then to find the actual note, then to load the CT scan...
There are multiple hard studies that show 33% reduction in efficiency that cannot be recouped.
Patients just love when you stare at a computer instead of talking to them....
This is crazy, I fight with my nurses every day. They tell me I have to input codes, I have to reconcile X, or Y or whatever.
F. That! I talk to my patients. I deal with them, and I deal with that screaming on the back end, but I'm not typical. I fight to talk to people like I would want to be talked to if I was a patient. I am burnt out, I can't fight forever. They will wear us down, your care will suffer. You let this happen, you asked for it through shitty laws that paid doctors 20% more to be part of a hospital system. You will suffer and you asked for it.
Practicing Surgeon MD
But how much of this analysis looked at the fact that if a doctor mis-diagnoses something, or misses something, they are immediately subject to massive lawsuits?
The litigation culture that pervades the medical profession, particularly in the US, makes it increasingly difficult for doctor to do their job properly, because if they deviate even slightly from "accepted practice" they end up served with a malpractice suit.
It is going to be fear of litigation, not poor IT, that drives the change in behaviour. That and the fact that a patient who can be sold care of some kind is considered a revenue-generator to be held on to. In other words, the healthcare system is no longer about the health of or care given to the patient, it's all about the relative profitability of the condition they bring.
This is what happens when you operate a health service on a financial model. Why are we surprised by this?
I once switched doctors because he spent most of every consultation oriented towards his screen and keyboard, entering symptoms, treatments, and medication into my medical record, and little time speaking with me face-to-face.
So you switched because your doctor focused on medical issues rather than providing you with emotionally comforting talk therapy?
You are not alone. If you look at doctor review sites, by far the biggest reason for low ratings is a rude receptionist. The 2nd biggest reason is doctors that avoided chit-chat. Actual quality of treatment and medical outcomes are rarely even mentioned.
Good intentions, maybe, and despite the grief there are some advantages. I can see my patient's clinic charts in the hospital - before, I'd have to wait for Monday and a fax machine. I can see what happened to folks in the emergency department. I can figure out my obstetric patients' prior pregnancy history. I can send records to specialists directly, and send requests with an electronic copy of a chart note and pictures of moles and whatnot at no cost to a patient and sometimes save them a visit to another office.
It's not perfect, but it's not a total disaster either.
It's 18% because health is a side benefit of an insurance system.
No, "better healthcare outcomes" is a measurment anomaly.
The fact that the average is dragged down because a large percentage of the US population doesn't get adequate health care is not a "measurement anomaly". It's an epic failure.
It's like a C average student claiming: "I'm really a straight-A student! I got As in all the classes I didn't flunk. (And BTW, for some reason my education cost twice as much as that of any other student.)"
Actually, I just don't bother to update it unless its billable. Best of luck tho!
>and the cash price he charges me is less than an MD that takes insurance would charge
Can confirm that one. One MD I work for must charge their clients more if they have insurance, insurance requires them to add a large number of tests and other unnecessary requirements on most visits. For most people the co pay ends up higher than if they just paid cash.
My doc asked me about family history of a condition. I told her my mom had surgery for the condition roughly a year ago. She started typing in the date, and paused:
"It requires an exact date. I can't enter an approximation. Can you by chance remember your mom's exact surgery date? They don't like dates that are off in case they want to research it.", she asked. (My mom is under the same provider.)
After pondering a bit, I suggested she see if there is a "notes" fields to indicate it's only an approximation.
"Hmm, let me see...", she replied.
After about 5 minutes of digging between screens, she said, "Okay, here's the doggon note section."
Table-ized A.I.
Not really, no. Countries with socialized medicine use the same drugs, the same machines and doctors with the same skills. They just bargain harder to get decent prices on in all. Some wealthy people do choose to fly to the U.S. but that's more about getting to the front of the line faster for elective procedures than anything else.
But even if you're correct, healthcare you can't afford might as well not exist. In that sense, the U.S. has practically non-existent healthcare.
No doctor can review a medical file in one minute.
I watched my doctor do exactly this with a real folder filled with paper just two weeks ago.
No, you watched a doctor scan a folder filled with paper for specific pieces of information. He did this first by recognizing the sheets of paper in order to identify ones that might have a diagnosis or prescription, then looking for the specific lines where that diagnosis should be written. If you think he absorbed the history of your blood pressure, weight, or all of the test results that might be relevant to your current condition, you're deifying a person just because his job is complicated.
Medical charts are like syslogs. You can read through them, and with some practice get pretty good at recognizing 'important' messages, or messages that fit with your personal expectation of how systems fail, but it's much faster and more accurate to have grep do it. This was, in fact, one of the big reasons to digitize those records. Software will miss a lot less than a human doctor who's been awake for 20 hours and is seeing his 25th patient of the morning. Let software compile and prioritize past diagnoses and prescriptions. Let software build a graph of body weight, blood pressure, and blood glucose going back for years. Let software summarize all that data and present it in a compact summary that's easy to absorb and easy to drill into more detail on the bits that turn up.
That's generally not what they have. What they have is record-keeping software that satisfies the bureaucratic requirements of the insurance companies and medicare. Its purpose is less for diagnostics and care; more for billing. It's what you get when you let accountants practice medicine.
So, the US spends 18% of its GDP on healthcare, but that only covers part of the population. Meanwhile those countries who only spend 6-9% of GDP on healthcare manage to cover everyone. So, that 18-6 cost disparity is actually understated
This is your argument that quality of care in the US is actually the best in the world?
I'm not really sure I care that a US millionaire can get outstanding care, if he can only do so at the cost of forcing the rest of the country to get 3rd-world quality care. I'm sure appropriately rich people in those other countries also get better than local average care. It's ridiculous to compare the quality of care available to the few Americans who can afford it to the quality of care available to an average 'socialized' medicine citizen.
We've had tort reform in some states. The effects seem to indicate that the cost of malpractice is responsible for a few percent of our healthcare costs.
I suspect what's driving our healthcare costs is that good healthcare isn't cost competitive. Our healthcare for most of us is covered by insurance companies through work. We change jobs frequently. Yet health problems can take years to have serious (and costly) effects. It's not cost competitive to prevent a problem that another company will likely end up paying for.
It's like the difference between owning a car you know you'll replace in five years and owning a car you will replace in twenty-five years - you're going to be much more diligent about preventing problems in the car you'll own for five times as long, because you'll be paying for the costly effects of poor maintenance.
http://www.nature.com/scitable...
I'll stick with the medical abomination for now.
"Whenever people agree with me I always feel I must be wrong." (Oscar Wilde)
There are so many layers of people siphoning their take that it's become almost absurd. More and more money gets pumped into the health care system, and physicians get paid less and less every year. We're one of the few industries in which an annual salary decrease is expected. It's insurers, more than anyone else - but also administrators, EMR vendors, pharma, device manufacturers, and government bureaucrats. And most of these industries have very effective lobbyists (unlike docs, who have the impotent and uninterested AMA), "representatives" (aka "salespeople") scurrying to & from doctor's offices, and aggressive direct-to-consumer advertising. All of the corporations involved in these activities are "people," of course, and operating completely within the law. Your healthcare dollars do very little to support your doctor - they are funding the medical industrial complex, which pushes the EMR for their own ends, not for the benefit of doctors or patients. I'm a cardiologist, and I can tell you from daily experience that the current practice of medicine has become an unbelievable slog, and EMRs are a large part of that - but the whole culture has become corporatized, to the detriment of the people it's supposed to serve. Hopefully the pendulum starts to swing back at some point, but I'm not holding my breath, and I wonder if it will be too little too late when it does.
It is not the doing of things that is difficult. What is difficult is getting in the right mood to do them. ~~ Brancusi
I've encountered medical scribes twice now:
1. During a trip to my ophthalmologist, the doctor did the examining and talked the entire time (not to me) while the scribe took the notes.
2. During my most recent trip to the ER (for a relative, not for myself), the doctor came in with a medical scribe. The scribe wheeled in a cart with a laptop and stood quietly in the corner. The scribe's job was to do nothing but take notes for the doctor while he examined the patient.
In both settings, the setup seemed to work very well. Perhaps this is the answer to the "over-data" problem described in the OP.
-- Stu
/. ID under 2,000. I feel old now.
Burn down the private healthcare industry and start over. As a society, we need to get back in touch with the basic fundamentals of what constitutes healing and caring for one another.
TFTFY
Nothing, absolutely nothing, has driven modern medicine so far away from the business of healing as has the insurance industry. Google the term "managed care", and weep for the days when physicians and other caregivers decided how to treat their patients. Worried about "government death panels" that decide who gets life saving care and who doesn't? Congratulations, sucker. That blatant misdirection worked on you too. In the U.S. we spend more (far more) and get less (by any credible metric) than any other industrialized nation when it comes to health care. To blame the physicians for this is absurd.
The quality of care that is _available_ in the US is the highest in the world.
The quality and outcomes of care for rare cancers and other rare diseases is higher in the US. But our quality of care for regular stuff, like 95%+, is no different than single payer countries. And in fact, for many outcomes, we are lower than other countries.