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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
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.
...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"
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.