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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.
As someone who works in healthcare IT, I understand where this article is going, and the costs associated with installation of an EMR are certainly feasible. However, this is NOT why doctors hate their computers. They don't want to do the part of their job that is arguably one of the most important. Documentation. They want someone else to do it for them. We constantly get requests for scribes to do that. It's PART OF THEIR JOB. That's like me not installing OS updates, not installing anti-virus. Stuff I'd prefer not to do but it's part of my job. Doctors don't want to do to it so they don't want the system to do it. Bad documentation from scribes leads to increased healthcare cost due to errors, and costs organizations because billing in many cases requires that the documentation be completed by the person who did the procedure.
It wasn't that computers are less efficient than old school / antiquated methods. It was a matter of incompetence. Before the transition all people involved should have been properly trained. 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. The data imports should have been tested properly. Printing issues should have been resolved in the piloting phase. Basically, everything was done wrong, but at least the Hospital Administrator's nephew got a new job out of the deal! (I don't know about that last point, but I do know non-tech people hire people they know, not people *who* know.
Guns don't kill people; Physics kills people! - John Lithgow as Dick Solomon on Third Rock From The Sun
I first went to Bumrungrad Hospital in Bangkok back in 2006; they had a fully electronic system then, and it worked great for the doctors. Some parts of the workflow are scanned in rather than electronic capture, and it appears the system has had minimal supplemental improvements in the intervening decade, but wow it works.
The doctors seem to love it because reviewing the charts and historical data is a breeze. As an added bonus, the hospital supports at least 5 languages, and the specialists don't need to be fluent in all as the system has automatic translations for common diagnostic comments with a backup human system for specialized comment translation.
Sure they could do more to streamline workflow with tablets or something, but they have a clean electronic medical record system that works. Not sure if it can track medicare codes automatically, but I am guessing it is a separate process.
As someone who spent 9 years working on HMIS systems, I can tell you that doctors hate what everyone hates: poorly designed screens and workflows that do not fit in with the efficient use of their time. One example: a vendor had a system for doing basic Order Entry - where, say, a doctor orders an X-ray. Along with a bunch of other unnecessary data REQUIRED to be entered, the system forced them to manually enter the date and time that the order was entered. No thought of: let's use the actual known current date and time that the order was entered. These types of inefficiencies were rampant and the vendor was truly perplexed why everyone hated the system so much.
Not just in medical. Jira can be configured to be easy to use... or to be "comprehensive". But when it gets too comprehensive, with too many fields required to do quick stuff, people just stop using it. I've aborted placing orders because they require I create a password, which I'd then have to track (put in my password manager), for what I consider a one-time-ever interaction... and then have odd password requirements on top of it!
Those extra required fields are the biggest problem with computerizing forms. On paper, you can skip them. And they don't need them anyhow. Your doctor doesn't need to know your job title, but now it's often required. Requirements creep - it's not just for PMs anymore!
It wasn't that computers are less efficient than old school / antiquated methods. It was a matter of incompetence. Before the transition all people involved should have been properly trained.
Having dealt with software system roll outs in health care, I think you are right in some cases but in others you are blaming the victim so to speak. My wife is an MD and her practice has a EMR system they purchased a few years ago. It's probably best in class for their type of practice but that doesn't mean it is perfect. My wife has spend literally entire days on the phone and in meetings trying to get fairly basic aspects of the system fixed. Simple stuff that even a lay person would look at and know that the software was badly buggy. That's time she doesn't get paid for to fix software that was rolled out before it was ready.
Let me be clear, the problems were NOT training - they were problems of very poorly done and buggy software development. To give one example, at one point if a physician assistant entered incorrect data early in the patient visit there was no mechanism whatsoever for my wife to correct that incorrect data later on. This isn't some rare corner case that doesn't happen much - this is something every practice will deal with multiple times daily. This is the sort of thing that can cause patients to get hurt if not corrected and it took them months to fix the problem.
Then there are problems of sharing data. The software at my wife's practice literally cannot talk directly to all but one of the local hospitals. Why? Because there is no economic or regulatory incentive for the software company to do so. They want medical practices and hospitals to use their software and nobody elses. So when my wife's practice has to send a patient record to an outside practice or hospital (happens daily) they have to use a fucking FAX or send paper records. Absolutely insane but that's the world we live in.
The only thing worse than electronic health records is staying with paper forever. Let’s implement an EHR system that everyone can live and then force those highly paid prima donnas to use it.
Every single EHR system I've used has had the same problem: The designers think they know my job better than I do. In the old days (1990s) you trusted the doc to write or type down the information that was important and relevant. Today, the EHR designers are worried that I'll forget to ask some clinically important bit of information (like the patient's smoking history), so they force me to fill out dozens of little boxes, check-marks, drop-down menus, etc., just to ensure that all of the clinically important questions are answered (with "clinically important" being defined by a committee of god-knows-who).
It's a fucking mess. Instead of a couple of succinct paragraphs, you get 30 pages of checklists and prefabricated phrases. There are several unintended consequences to this-- when doctors have to click through dozens of checklists (some of which may be of questionable clinical importance), they get in the habit of doing it as quickly as humanly possible, and that's when mistakes get made. That's how you end up with notes that say "Pelvic exam performed and was normal. Prostate exam performed and was normal." Of course, no one would actually TYPE this shit, since it doesn't make any sense-- these are phrases that got inserted into the chart because someone "clicked through" a wall of checkboxes.
You also wind up with situations where you are forced to choose from a limited number of wrong or partially-wrong answers. (I've run across systems where instead of being able to describe the patient's affect, you had to choose from a selection of about five different adjectives to describe the patient's affect).
Look, I get it. Doctors are imperfect and sometimes they really do forget to ask certain questions, perform certain parts of the exam, or issue certain warnings. I'm of the opinion that we need more mechanisms to double-check the work doctors do. But this should NOT be the job of the software developer who writes the EHR software.
...with private medicine in one phrase:
the expenses came from lost patient revenues
When patients are revenues, who's interested in curing anything?
"Encyclopedia" is to "Wikipedia" what "Library" is to "Some people at a bus stop"
Have to heartily disagree with that comment. I've worked a couple of different IT positions in healthcare, and the main reason doctors "hate computers" is they tend to be heavily resistant to any sort of change, and the nature of software is change. Years ago I had a gig upgrading computers in a hospitals and the doctors were by far the most hostile towards mandatory upgrades (compared to nurses and receptionists, who were generally eager to get a new computer). God forbid their desktop icons were rearranged, or something didn't work exactly like it did. Most EMRs (software for maintaining electronic records) still have a Win 3.x look and feel, you can't make any changes to the software they use without risking major conflict with your BAs and the doctors they have to deal with.
I can only speculate as to why doctors are particularly against any sort of progress change, or as to why they are absolutely set in their ways. Perhaps any sort of short term loss in efficiency / patient care is unacceptable - like some sort of variant of the Trolley Problem where "pulling a level" hurts patients in the short term? Because their existing systems are working, they don't want to take any sort of risk that may reduce their down time?
Global warming and other natural disasters are a direct effect of the shrinking number of pirates - Gospel of the FSM
Like it or not, it's called accountability.
People with heavy debt and wealth (medical professionals as an example) are the among the first to call on "the system" to hold others to account.
What's happening now, is the system now can and does now hold them accountable... And they don't like it one little bit!
When we ask for justice... It's usually meant for others to be brought to justice, granting relief to us.
It's a knife that cuts both ways though and we always think it's unfair when it cuts our direction.
Maybe it's time to look for something other than "justice", eh?
The gun question has nothing to do with the government. Nothing. And, further, all patient / physician interactions are private and protected interactions.
The gun question is there to keep you (and especially your children) safe. If you answer 'yes,' they can provide information about gun safes, trigger locks, safely storing a gun. If you answer 'yes,' they may also check your mental health status or ask about any thoughts you might be having about suicide. In this context, asking about guns are for your well-being and protection, which is what concerns the physician rather than politics.
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.
Your doctor doesn't need to know your job title, but now it's often required.
You say that as if it were obvious, but the kind of work you do may well be a factor in quickly and accurately diagnosing your condition. Should it be a required field? Maybe, maybe not—but if it's not required then they're less likely to have that information available when it would be genuinely useful.
"The state is that great fiction by which everyone tries to live at the expense of everyone else." - Bastiat
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.
Like I said, we need to develop an EHR standard that everyone can live with. This, like winning WW II, takes work, but there is no viable alternative. And i don’t mean incompatible islands of technology centered in a few major hospital systems, I mean one nationwide, online medical records standard whose use is mandatory and non-negotiable. Make knowing how to use it as basic a part of med school training as gross anatomy.
Last year my mom (age 96) was taken to the ER with acute intestinal distress. As she was being attended to by the ER staff I mentioned that fifteen years ago on a visit to California on a book tour, she had been taken in with similar symptoms in the desert town of Ridgecrest, and that the diagnosis back then had been diverticulitis. “Diverticulitis? Hmmm...”
“So can’t you bring up her records and see it there?” I asked. No, apparently, it’s all on f* paper, in a town in the middle of the Mojave Desert, and they have to “send for it.”
When your consider the massive amount of money we are forking out to you people day after day, this is beyond pathetic. Suck it up and learn some methodology worthy of the twenty-first century.
From what I recall some explosives are toxic and could cause abdominal pain, vomiting and seizures. Potassium nitrate causes abdominal pain, so if one has old fashioned gunpowder and mishandles it could get abdominal pain and diahrrea. I know it because I like to watch police procedurals.