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Why Doctors Hate Their Computers (newyorker.com)
Digitization promises to make medical care easier and more efficient. But are screens coming between doctors and patients? Here's an excerpt by Atul Gawande of The New Yorker, which talks about the deployment of Epic, a new medical software which cost Partners HealthCare a staggering $1.6 billion, panned out: On May 30, 2015, the Phase One Go-Live began. My hospital and clinics reduced the number of admissions and appointment slots for two weeks while the staff navigated the new system. For another two weeks, my department doubled the time allocated for appointments and procedures in order to accommodate our learning curve. This, I discovered, was the real reason the upgrade cost $1.6 billion. The software costs were under a hundred million dollars. The bulk of the expenses came from lost patient revenues and all the tech-support personnel and other people needed during the implementation phase.
In the first five weeks, the I.T. folks logged twenty-seven thousand help-desk tickets -- three for every two users. Most were basic how-to questions; a few involved major technical glitches. Printing problems abounded. Many patient medications and instructions hadn't transferred accurately from our old system. My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem.
Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called "the Revenge of the Ancillaries." In building a given function -- say, an order form for a brain MRI -- the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn't even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with "field required" alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
In the first five weeks, the I.T. folks logged twenty-seven thousand help-desk tickets -- three for every two users. Most were basic how-to questions; a few involved major technical glitches. Printing problems abounded. Many patient medications and instructions hadn't transferred accurately from our old system. My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem.
Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called "the Revenge of the Ancillaries." In building a given function -- say, an order form for a brain MRI -- the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn't even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with "field required" alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.
I remember fondly, when one doctor called me to complain about my program I wrote for him
He said it behaved erratically, especially if they lay down a heavy binder on the keyboard to check something.
If something like a Field Required is a terrible inconvenience, a bridge too far, an insurrerable inconvenience that destroys th eprecious time that the doctor spends with their patient.........
Yer doin something wrong doctors.
If there is one thing about the medical profession that needs changed badly, it is the concept that doctors are some sort of infallible super being who dare not be questioned.
tl;dr Hey doc? Just fill out the damned form.
The shepherds did so well protecting the flock that the sheep no longer believed that wolves existed.
They shouldn't have made a mass transition to the new system, but rather should have piloted it with a small group of the best in class as the first users, who would then be in a position to help their colleagues thereby greatly minimizing the need to involve IT.
That might be about the most tone deaf stupid, IT think I have seen in a long time. Look have you any idea how a hospital operates? Its not like a GPs office. Nurses change in shifts. Different specialists see patients; You might have one attending physician overseeing the entire thing but the anesthesiologist, dietitian, physical therapist, gastrointerologist all need to see the same patient and they are never scheduled in a room together. Their entire communication is via charts. Oh and even the kitchen gets sent food prep instructions - per patient via the 'system'
You simply can't pilot something with X users, at hospital scale. Won't work. The best you can do is ask X people to do double entry for a little while to see if they hit any issues but the rest of the practice at large is going to still be using the old system.
Your choices are either hot cut - or - full scale integration between the new system and the one you are retiring; and all the bi-direction data translation and real-time synchronization issues there in.
Repeal the 17th Amendment TODAY! Also Please Read http://www.gnu.org/philosophy/right-to-read.html
Consider the alternative. The guy who's responsible for recording exactly what my condition is, and what my treatment plans are... does not actually have medical training?
We have that already. It's Dragon NaturallySpeaking, and an endless source of amusement is seeing how badly it misunderstands what the doctor says, because it doesn't understand the context.
You do not have a moral or legal right to do absolutely anything you want.
I have to stay anonymous, but I'm in agreement w/ about 50% of what your saying.
Epic is a beast, it's a fully integrated system of about 30ish different modules 10+ "core" ones that glue together to form the Voltron of patient charting. Each module requires substantial training, and about 3 years experience for a seasoned IT analyst to be competent, but much of them are clinical converts with little IT knowledge but lots of medical knowledge. Training up support staff is hard when that much experience is required just to feel comfortable, plus they may not be the best computer people to start with! Good consultants can easily make $100/hr. It takes much more time to be in the top 25% who can also earn more. The thing is, you can't know enough! Knowing a little about each module and you won't be very effective. Specialize in just one and you won't be effective. You need to know a LOT about the relationships between them, and how to navigate those. Printing? Yeah we have tech dress rehearsal for that, that's gross negligence by IT. Data migration? It's not as easy as saying the words. Mapping takes a long time, is often done w/ excel because there's no "Conversion utility" between 1 brand and another. (write one that works 100% of the time, and you might get rich!) You can't test every map w/ human eyes, there's too damn many of them. Look at the CPT code book to get a good idea of why this is. Also, human nature never checks the negative test. I have to constantly remind my team that just because something works as you built it doesn't mean that something else didn't break.
Ancillary systems have historically taken on risk that is outside their scope, and now their pushing that back to where it legally belongs, and yes doctors don't like it. Usually the older ones.
Caveat, I'm biased, as I work in the field. Epic has it's faults, don't get me wrong, it's a complicated beast. I hated it for the first 4 years that I worked on it. Now? Now I "get it" and am blessed to have had the opportunity to have worked w/ it.
Once I started a new job which had a few nice things like getting reimbursed for decent home Internet service (because I was on call). But the system used to request reimbursement was clearly designed for the people cutting the checks, not for the people entering the requests, so after three months I just gave up and paid for my home Internet service the old fashioned way, out of my own damn pocket.
The fundamental problem is that whoever is designing the system gets to choose where they can freeride. If an insurance company designs the system, they're going to push work off on medical facilities and doctors. If a hospital designs the system, they're going to push work off on doctors and nurses. If doctors design the system, they're going to push work off on medical facilities and insurance providers. The key problem is that patient representation is lost in the process. If you stepped back and said "What option would provide the best patient outcome?", you'd start to consider questions like "How do we ask this question to get the best data, but to prevent people from getting irritated and pushing random buttons to make progress?" So, often a required field goes from having one of two or three answers to including options like "I don't know" or "Not applicable". And just to be safe, there should be a "I don't want to answer", so that you know whether or not the doctor actually thought about the question, rather than just pressing "Not applicable" to get the question to go away. Then, of course, you need people designing backends to reflect this ambiguity.
Unfortunately, it's easier to just force a selection at the front end, even though it messes up your data. So you can say with 100% confidence that a particular question was answered "Yes" or "No", but you have no confidence as to whether the person answering the questions actually made any effort to have them correspond with reality.
Let’s implement an EHR system that everyone can live [with]
Well, that's the hard part, isn't it? They are almost universally despised. My workload has increased significantly since my hospital implemented an EMR, and the only thing that has improved vs paper is that you can read everyone's writing. Of course, those relevant nuggets of information are now buried in pages of auto-generated "content" that load slowly, so they're not necessarily easier to find out.
I'm an anesthesiologist, and my job is not like that of other doctors. Unlike the vast majority of doctors, I don't get paid to write notes with more details. My notes are very, very brief. I can write down "healthy" and leave it at that, and still get paid. What I do have to do is find all those nuggets of information. In the previous system we had, charts were done on paper, and scanned in after discharge. Lab results and anything dictated (operative notes, radiology results, pathology results) were easily found in the computer. Now? Happy hunting. My note auto-includes all recent radiology results, even when they are irrelevant to what I'm going to do. If I want a nice, clean note that is in any way as concise as my paper notes were, I have to go and delete all of that manually.
There's a nice little section where diagnoses are entered as the patient comes into the system. If someone has put these in, it auto-populates. Great, right? Except that if you've ever been pregnant, then "pregnant" shall forevermore be on your list. I have to hover over a very specific box to delete that when, for example, you've had your baby. Or babies - I'll get one "pregnant" diagnosis for every one of those. It helpfully includes information like whether the patient is sexually active or not - even if the patient is currently pregnant. There is no reason that should ever appear in my note, because the only thing that is relevant to me is whether or not you are currently pregnant.
So, just to make a simple example, let's have a healthy 19-year-old woman with appendictis. No allergies, no medications, no prior surgeries, no family history of anesthetic complications, normal airway exam, brief list of labs, negative pregnancy test, plan general anesthesia, ASA physical status 1E. That is what my paper note looked like. The EMR note would fill pages.
The thing about paper medical records, for all their faults, is that they were a highly refined method for transmitting maximum information in minimum space. Even after the entire rest of the VA had switched to electronic records (and although the backend was apparently a nightmare, the user experience wasn't too awful), anesthesia records were done on paper and then scanned in, because they occupied the front and back of one sheet of paper and were dense with information that just can't be represented in text. Even simple things like blood chemistry were typically recorded in a skeleton so that you didn't have to read line-by-line.
Having said all that, every doctor can tell you something similar about their own specialty. Irrelevant or incorrect information clogs notes, especially as they are more or less cut-and-pasted day to day, with the newest day usually coming at the bottom. I was investigating a case where a patient who was in the ICU quit breathing and had to be intubated. It happens, no surprise there, and one of the physician notes written at the time suggested that it was correlated with starting a specific medication. I decided to look up the nurse's notes to see whether that was true or not - ICU nurses are a dedicated bunch, and there's no way that it wasn't documented. In the ancient days, that would have required a trip to medical records. In the immediately-past system, I would have been able to pull up the scanned i
It's not holding them accountable for their clinical decisions (which is the kind of accountable people think of in this case), it's all about accounting for billing purposes. Some of this data is useful for research purposes and yes some of it can be used to figure out what went wrong in a course of treatment. Unfortunately it also reduces doctor throughput and draws their attention away from the patient in front of them.
We need to look for solutions that reduce the time and attention required by this software as much as possible. Some of this is simply capturing data directly from medical notes, voice recognition and smarter software (ensuring you don't have to enter the same thing into two different bits of software). The rest is being brutal and removing unnecessary/unused information.