NOSH ChartingSystem

A new open source health charting system for doctors.

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So much money for so much nothing – dire straits for electronic health records

I’ve previously written about my experience with poorly designed electronic health records and how it negatively impacts provider happiness and patient safety.  Apparently, I’m not alone in my experiences and my sentiments about this subject.

First, we have a study that validates the concern that EHR’s waste time for doctors.  Imagine the impact for primary care physicians who are already crammed for time, seeing patients in short time intervals just to keep their overhead.

Then, we have Dr. Clem McDonald, one of the pioneering physician champions for EHR’s at the Regenstrief Institute in Indianapolis and the author for the study, lamenting how a 5-year, $27 billion Meaningful Use Incentives legislation to encourage EHR adoption by physicians was a disappointment and a tragedy.

The players on the Meaningful Use stage are now starting to walk away.  First exiting is CCHIT, the governing body that somehow gave us the great idea of thinking that EHR’s need to be certified on the condition that they be expensive and that doctors need to somehow prove that we can use an EHR in a “meaningful” way, never mind that doctors then forget how to talk to patients and only clicking check boxes and safety measures are ignored.

Then the numbers for those who have attested for Meaningful Use Stage 2, due at the end of this year, are absolutely dismal.  Just looking at the data up to September, 2014, we had a total of 333,454 eligible Medicare providers.  Of those, 80% (266,067) successfully attested for Stage 1.  And now (with the deadline for Stage 2 ending at the end of this year), we have less than 1% (2,282) who are successfully attested for Stage 2.  I feel bad for the folks that put all their efforts into Stage 1 and are now stuck. (99% of them)  So much for the incentive money.  So much for using EHR’s meaningfully.  Apparently doctors don’t know how to use an EHR correctly because we doctors just don’t understand how to use a system that is supposed to be used by doctors.  But we now have some really happy EHR companies that have their physicians captive to their expensive, unusable system.

To add insult to injury, even patients don’t even trust information stored in the EHR’s because of their concern for data security and privacy.

I also point to Exhibit A where I personally used a big vendor, multi-million dollar EHR recently (unfortunately the same as this one) and I noted that there was an erroneously entered diagnosis code after a lab interface attempted to duplicate an ICD-9 code, but incorrectly selected a different one instead.  I didn’t want this poor patient to be an example of where an EHR virtually gave them syphilis, so I diligently attempted to try to remove this ICD-9 code from her problem list and chart.  Alas, no matter how many different ways to outsmart this EHR (and with my hacking skills, no less), I was unable to do this.  I thought that since I was a practicing physician, I should have the privileges to be able to edit it.  I also incorrectly assumed that since an EHR ought to have auditing features, removing an ICD-9 code would be noted (in the case my action to remove it might be construed as erroneous, at best, and covering up something nefarious, at worst) anyways.  So in desperation, I contacted tech support.  I was told that it couldn’t be done once an ICD-9 code has been associated with an order.  But then I said, well, I tried to reorder it without the wrong ICD-9 code, and yet, the code still appears in the chart.  They said, that once it’s even on an order that was redacted, an ICD-9 code cannot be removed from the chart.

No wonder, patients can’t trust the information in an EHR, because shenanigans like this keep a doctor from keeping the chart as accurate as possible.  But for that poor tech support person, I suppose they figured out a way to remove it at my persistence.  Chart correction in this EHR apparently is such a difficult process that can only be achieved through tech support privileges, which appears to be higher than a physician user privilege.  What does that say about the role of physicians and their EHR’s if the EHR won’t let physician’s use their medical knowledge to enter data?

With these examples, what’s the point of using an EHR anymore?  As a physician, a patient, and a citizen, I can’t believe we spent so much money ($27 billion) on so much nothing.

Music video for Money for Nothing from Dire Straits

On the flip side of what appears to be dire straits for the EHR world, we have patients that reportedly yearn to be more proactive with their health through online technologies.  First, a 2-year study from the ONC, revealed that despite privacy and security concerns, patients prefer that their physicians use an electronic medical record instead of a paper and pen.  Regarding patient engagement, an online survey performed by an EHR software research company, Software Advice found that 60% of Latinos would be willing to access their medical records online so that they are able to track their diabetes-related health risks.  Furthermore, 54% of Latinos say they would be willing to log and send personal health information electronically at their doctor’s recommendation if they had the means necessary.  Lastly, regarding patient collaboration, we have a recent study from the University of Chicago, University of Massachusetts, and Geisinger Health Systems that show that patient medical record accuracy can be improved with systems that incorporate patient feedback.

We have physicians who are trying to marry unique practice models such as direct pay practices and EHR’s that aren’t constrained to Meaningful Use incentives, including EHR’s home-grown in these innovative practice models (like yours truly and Rob Lambert’s).

So how can we harness the patient and physician’s desires and frustrations to overcome the dysfunctional status quo of health IT and Meaningful Use?

Whatever the solution is, below are what I believe must be the fundamental guiding principles going forward:

  • Use of open and modern API standards (like FHIR) for the digital exchange of information.
  • Ease of use for the physician and patient (OMG, why the user experience for an EHR is everything!) so they can enter their data without disrupting their workflow.
  • The cost of entry must be low for patients AND physicians so that no one is excluded.
  • And for the sake of data privacy and security, the data must aim to be decentralized and not stored by one monopolistic entity.

This is a vision of a different kind of interoperability, where physicians and patients collaborate on a unified, modern, AND secure personal health record…that is not wholly owned by a third party entity, but primarily owned by one entity that is truly meaningful…the patient.