EHR: A Lesson in 'Wants' vs. 'Needs'

I've been able to dodge the EHR bullet for a long time, but no longer. It has taken 18 years for the hospital where I see patients to finally implement a system. Today is the day it "goes live" (an oxymoron if ever there was one). Lord only knows how we managed to survive for the past 18 years without this piece of absolutely "vital" technology.

Will the patients be better off? Will the doctors be better off?

From my own experience, patients want:

• Competent doctors – I'm satisfied that we have them.

• Access to care – I don't think the new EHR will affect that, unless it takes away flexibility to overbook or see walk-ins. There are indications that this may well be a problem.

• Convenience – Our amenities are attractive but the amount of "red tape" is not. Once they arrive, they get financially screened, wait to see the doctor, wait for the doctor (resident) to do the obligatory computer entry and review everything with the attending, wait in the lab, and then wait in the pharmacy. Neither our old computer system nor our new one help to speed up these steps, therefore I presume that visits will take as long, if not longer, than before.

• Communication – Historically, our patients tend to move frequently and have been hard to reach. Cell phones have helped a lot. Still, the level of communication is sub-optimal. The resident's schedules are filled with teaching conferences and limited by the work-hour rules. They have little time to actually keep tabs on, and in touch with, the patients. I had these same problems with my physician until he started communicating through a patient portal. Our new system does not currently offer a patient portal.

From my own experience as a doctor, the thing that keeps me from doing my best is my memory. Like everyone else, my short-term memory can only keep track of four things to eight things at a time. In the course of a complex encounter, many more than eight things occur to me that I intend to do for the patient. Unfortunately, by the time I've started charting the visit and writing the orders, most of those things have slipped my mind.

If an EHR is going help me, it should have a powerful, easy-to-use means of creating reminders (especially while I'm working directly with the patient), receiving them in a timely, unobtrusive manner and responding to them. From what I can see, our new system offers no help here.

The other thing that I need is also related to memory. Our new system has functions scattered over a myriad of tabs, screens, and forms. We have been given pages of printed instructions that we are supposed to remember to follow because the system can't or won't guide us, but even if we remember everything, just finding it is a challenge. If we forget to follow the instructions, the patient may suffer.

Here are a couple of examples of the things we're admonished to remember:

• "Choose the right note type." (There is a long list devoid of descriptions. Which ones are "right"?)

• "If a stat or timed order is submitted with the default collection priority set as 'nurse collect:no,' the order will not appear on the nurse's task list, which could delay sample collection. Thus, it is imperative that each provider ordering stat or timed lab tests verify the collection priority, and if necessary, change the 'nurse collect' order detail to 'yes' before signing/completing the order."

People simply cannot remember to do dozens, or hundreds, of things, without some sort of assist. An EHR should provide that assist, and without it, care quality can only suffer.

 As author Jeff Davidson said in "The Complete Idiot's Guide to Getting Things Done": "When your brain is always engaged, when your neurons are always firing, when you find yourself in a continual mode of reacting and responding, instead of steering and directing, the best and brightest solutions that you are capable of producing rarely see the light of day."

As a technology, using a typical EHR limits the number of patients that a physician can see. Organizations that use EHR have been forced to lengthen visits and hire more doctors. Operating costs have mushroomed are represent real dollars. The "benefits" of EHRs are mostly intangible. It will be interesting to see if the intangibles justify the billions of real dollars that are being spent on this stuff. At the moment, though, it's hard to see that either the patients or the doctors are noticeably better off.