With Any EHR, Theory is Important but So is Practicality

Hardly a day goes by when I'm in the clinic or the hospital that I am not regaled by a physician with some gripe, problem, or question about EHR or the “nonsense” that accompanies an organization's attempts to implement and use one. The "regalers" include physicians who work for Kaiser, a couple who work for federally qualified health plans, a number that work in teaching hospitals, and some in private practice. None of them is ecstatic about the computer systems or the amount of extra work they require.

Some Kaiser docs are reasonably happy with the results of their effort. They like being able to find the information they need about patients and their income is not impacted by the fact that the EHR has decreased their productivity. They recognize however, that the quality of the information that they find is highly variable, depending greatly on the compulsiveness, diligence, and commitment of individual practitioners. Some notes are useful and trustworthy, others are not. Some loops get closed, others do not.

What I've been trying to do, and will continue to do, is to introduce you to the concept that some of the undesirable characteristics of EHR systems have causes that lie deeply rooted in design decisions that either were made decades ago or are a direct consequence of inescapable limitations and rigidities that arise in the programming languages, databases, and operating systems that have been used to build these EHRs.

These problems cannot be solved by the medical software vendors or by the average physician. The solutions lie in basic research by computer scientists. The average software designer, programmer, or practitioner of medical informatics is neither a computer scientist nor in a situation in which research would be possible. The government funds a great deal of computer science research but so far hardly any of that support has been devoted to EHR-related issues.

Evidence-based medicine strives to employ techniques that have been proven through scientific research to work and to avoid those for which there is no such evidence. Should you demand any less from your EHR? Should it not be based on sound, scientifically validated theory and proven to be safe and effective? If customers make this expectation one of the requirements that their EHR must meet, then vendors will have a strong motivation to support basic research and use the results. On the other hand, if customers remain passive and allow the vendors to make the decisions, the status quo will continue.

So, for the time being at least, most of us are stuck with EHR products that have lots of warts and there is no immediate cure for warts in sight - but life must go on. What we need is “outside the box” thinking: creative, innovative ideas for how to use what we have available in ways that minimize the pain and maximize the gain.

Physicians using EHR find it difficult and frustrating to use the applications. Most find that they can see fewer patients per day. Some have compensated by employing scribes to shadow the doctor and do the data entry. Some practices hire their own scribes. Other practices obtain scribe services through firms like Physician Angels which provide scribes who work at remote locations but connect both to the doctor in the exam room using the Voice Over Internet Protocol (VOIP) and to the doctor's EHR. The scribes listen to the exam and the doctor's instructions and do the necessary typing and/or data entry. By the time the visit is over, or a few minutes after, the encounter is complete in the EHR and ready for the doctor's sign-off. Practices using scribes report that they have increased their patient volume by more than enough to recover the cost of the scribes and one suspects that, for those doctors that find the scheme workable, it must be a great stress reliever.

Using scribes does not, of course, do anything to correct the intrinsic defects and deficiencies in an EHR which will continue to fester and produce problems in the future. If practices can become more profitable by spending money to assist physicians, just imagine how much more profitable they could be if physicians could actually be productive with EHR and this palliative remedy was not necessary.

I call this to your attention, not because I am promoting the scribe scheme but because it serves as a great example of what can be done if you take charge of the way you are going to practice and of how your office is going to run instead of having an EHR coerce you into doing a whole bunch of unpleasant, inefficient stuff just to keep their horrid software happy. I'm sure that more “outside the box” thinking can produce more interesting solutions, so I challenge you to keep thinking and to strive to retain control of your practice.

Find out more about Dan Essin and our other Practice Notes bloggers.