Part One: What is Wrong With Healthcare in the US? A Physician Perspective

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First issue is electronic health records. Worse than insurance companies, this is the main thing that causes frustration, wastes time, and sucks the life out of me.

I have yet to meet a physician who actually likes their EHR. I am not sure why that is except that they virtually all suck.

Ten years ago I used a program called Epic. It was pretty awesome back then. I have no idea what it is like now. Currently, I use Centricity. Epic ten years ago was light years ahead of Centricity now, which should be embarrassing to GE. I really don’t think they care, though.

In the process of job interviewing I have played around with a couple of other programs: EClinicalWorks and NextGen. NextGen is way behind Centricity. Awful. I didn’t think that was possible.

Anyway, here are the top things I need from an EHR:

1. Fewer clicks to get the job done. I don’t know who the hell develops these programs, but they are not using them every day to see tons of patients, I can promise you. It takes me over 200 clicks to navigate a well child visit. Sometimes very common actions are buried in 2 or three layers of clicks. Makes me want to pull my hair out. I could shave 30 minutes off my day, easily.

2. Order time outs. If I order a test and a result does not come back in a week, I should get a notice that it was not completed. This is a safety issue but very few EHR’s think it is important enough to include. I had an IT guy say this sort of thing was not available anywhere. Wrong. Epic had this capability ten years ago. (You other people are robbing physicians and patients of a very powerful tool!)

3. Patient instruction handouts that are brief and to the point. I need a section at the top to free text my instructions. An active medication list. Discontinued medication list. New and changed medications (and which pharmacy they were sent to). Preventive care info (like when the last tetanus booster and mammogram were done). Vital signs from today’s visit. Date of next appointment. Cram this all onto two pages otherwise patients won’t read it. Our last update took the average length of the patient instructions from 3 pages to about 15. What the hell? Who has time to read that kind of crap? Granted, part of this was because of “Meaningful Use” mandates from the government, but that deserves its own special post…

4. A patient portal that meshes well with the EHR. A portal is where patients can get their lab results, copies of imaging reports, send messages to their doctor, etc. Ours goes to a completely different, isolated section of the EHR and is a pain in the butt to use. I cringe when a patient sends a note because it is a ton of work. In fairness, not all portals mesh as badly as Centricity’s does. Really, ideally, the interface would be seamless.

4. A stable system. No crashes. No ghosts or flukes in the system. It is terribly disruptive in the middle of a busy clinic to have to sit on the phone with the help desk for 20-30 minutes only to be told, “It is a known problem and we can’t fix it. We have engaged the vendor for a solution.” That is IT lingo for, “Suck it!” And I do. Because it rarely ever gets fixed.

5. Good grammar. So many of the visit templates that have you click symptoms or exam components put them together using gibberish or terrible sentence structure. “No masses and enlarged prostate.” It should say, “Enlarge prostate, no masses.” Missing punctuation. Stilted syntax. If I really spoke or wrote this way my clinical skills should rightfully be questioned. This infuriates me. I do not pretend to be a master of the English language but there are some basic tenants that should not be ignored.

6. The ability to free text at will. I like for my notes to tell a story. One program does not allow much free texting in the history of present illness section for example. Instead of being able to say, “The patient was riding her horse when she happened upon a paper towel that startled the animal. She was subsequently thrown to the ground and trampled repeatedly.” I would have to say, “The pain in the chest and arms and legs and back and head started on 2 hours ago. The quality is sharp. The severity is 10/10. The duration is constant.” This tells you nothing about the horse or the nature of the accident which is an important detail as it helps to indicate this is likely a serious injury, not to mention the grammar issues (see #5).

7. An easy way to see which preventive care items are due. I want a page that shows me what the last blood work was for a diabetic, when the last eye exam occurred, and if the numbers are all at goal. I want to be able to look further down the list to see when your last PAP was done and if you are due for your shingles vaccine. I do not have time to go searching through the entire frickin’ medical record to find each and every one of these things each office visit.

Bottom line: I want all of these things in ONE package. One program. Not 2 or 3 items. ALL of them.

Why can’t I have this? Physicians are pretty unanimous about what they want. Why can’t a single EHR deliver?

This is my theory:

Early on, groups made decisions about electronic health records based on cost, not quality, thinking incorrectly that they would get to help improve the system. Yet once they were a year or two down the road into an EHR and realized it was awful, it was too late. Switching means the potential of quite a lot of lost data, TONS of work preloading charts. Plus the frustration of learning an entirely new system. Once a company has you by the balls, they know they do not have to provide quality enhancements. All they have to do is make a passable attempt to try to “improve”. Then they can just kick back and reap the rewards in the form of big fat checks.

It is blackmail, essentially.

We let them get away with it, though, so we are all willing accomplices.

I am sick and tired of hearing at interviews, “Well, there is no perfect EHR.” Look we have smart phone apps that do anything imaginable, virtual reality games that are crazy realistic, and we have 3D printers for crying out loud! You cannot tell me that there is no one out there smart enough to make an EHR that is good, that is something to be proud of, that can save the lives of patients and doctors and nurses and ancillary staff.

If you are that person, I will be happy to help you!!! Meanwhile, if you are reading this and really do love your EHR, I would to hear which one you are using and why you like it so much!

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50 thoughts on “Part One: What is Wrong With Healthcare in the US? A Physician Perspective

  1. I’m so excited to read this series. Thank you for sharing!

    This sounds like a great opportunity for a group of entrepreneurs to tackle. Ideally the group would consist of at least one doctor, a nurse, a PT, OT, etc….. any person that would be utilizing the tool. Although this doesn’t solve the issue of the time/expense to backtrack all previous records. But maybe that could be a feature of the program.

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  2. I use a program called Genie. It is created by a surgeon’s brother who studied IT. It was created for surgeons. It has some minor glitches but absolutely amazing to use! The best thing I love about it is its flexibility…. If you prefer to draw a picture or hand write something (e.g. A diagram for consent), it can be scanned in and categorized correctly amongst the other notes. Photos can be attached as digital files, operating notes can be typed and sent/printed as a report, a letter or an attachment. All pathology can be automatically downloaded and flagged if there are anything out of normal range (until you review and unflag it). The recall function is also good for unchecked results and patients who have not been reviewed. And it does billing, financial reports and generate cross sections on the types of procedures, referrers and other demographics. Ok… I will stop rubbing it in now…. 😛

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  3. The only reason I have any idea what you’re talking about, is that my doctor expressed the same frustrations with me. Anything to make my doctor’s job ‘easier’ and less frustrating is good with me!

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  4. I had to chuckle at the beginning of your post. After breaking my foot, I had a number of follow-up visits with the orthopedic guy, who was (I would guess) in his late 50’s. On every visit, I watched the poor man struggle with the computer, clicking to get into the program, then clicking to find my patient name/number, then clicking to find my chart, then clicking to find my x-rays, and finally clicking to enter his notes for that visit. And this was in an orthopedic facility that prides itself on its efficiency in getting patients in and out quickly! Modern technology is great, until it isn’t.

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  5. All my doctors have shifted to electronic. Some things seem better but it takes a lot longer to find things in my record. My dermatologist has the nurse tech that accompanies him do most of the input. My surgeon dictates into a machine and I think someone else does it.

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    • EHRs are better than paper (I spent 3 years on paper and it was torture) but by golly they require staff that suffers from OCD who will put info and documents into the right sections labelled correctly.

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      • I can hear your pain. I worked in health care insurance before retirement. We had a very hard time coming up with a claims processing system. We have 3 huge failed attempts (to the tune of millions of $$). I too can’t understand why the commercial things, smart phones and such, have such ease of operation but they can’t simplify processes for business programs.

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  6. We’re on PRISM. I was here when it rolled out and now that I use it daily, it has become clear to me that they violated Rule Number Effing 1 of designing technology: ask the user what they need. See, before I was in medical school and doing this whole baby doctor thing, my first career was basically basically to use and sometimes build technology for use after disaster to avoid embarrassments like Katrina or old ladies on dialysis with no care for a week. Just small things, really. When were those projects successful? When I worked with the people who had to use the system to design what they wanted, not what I thought they did on a daily basis. To me, EHR is a perfect example of engineers and IT guys doing an impression of what doctors do all day. While I’m ranting (boy do I feel better), can we delete whatever button it is that allows me to delete an entire note without a warning button? Thanks. S.

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  7. I worked in the UK (NHS) until very recently. The Trust I was working for decided to design their own system. We were a psychiatric trust. No, I can’t say it worked very well either. And of course it could not communicate with any other systems around very well. I’ve always wondered too why commercial programs and companies seem to be able to get systems that are adjusted to their needs. You also have very strange counter-intuitive expensive contracts that seem to tie institutions forever…

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  8. Sorry that went out too early … I meant to say I ❤ your Blog! It's so refreshing to read a non-conforming medical practitioner's take on their own profession 🙂 Well done!

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  9. Switching over to electronic records was the most stressful time I ever encountered in practice. One can easily use the entire patient visit just typing in and clicking all the necessary info. Before you know it, the office visit is over. Really hard to stay on time. I have experience with All Scripts and a little bit with Epic. EMRs are necessary, but they don’t always simplify things, that’s for sure.

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  10. Great blog post.

    It’s just not right that we can’t get these things right. But that shouldn’t be much of a surprise, really. It’s just one more aspect of a messed-up thing we call healthcare. A few years ago, when Kaiser was rolling out its system, I knew an RN in one of their labs. It was a real pain in the neck and a lot of additional stress to an already difficult job and work environment. The whole time, we (the public) were lead to believe that the company’s feats were unmatched. The wonderful folks at Kaiser had landed a Toyota Prius on Mars or solved gridlock in Washington DC.

    And who knows? Maybe they have by now. Four billion dollars goes a long way, even on IT, if spent wisely.

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  11. The company I work for does a lot of research using EMRs — they are invaluable for that.

    As a patient with a zillion specialists, I love EMRs — because I don’t have to constantly spend my OV on reiterating my medical history. I actually choose doctors who are affiliated for that reason (among others)

    But there must be a way to improve this technology. I’d never heard this side of the issue.

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  12. I used to work for a company that created EHR programs and I had to smile at your example: “The pain in the chest and arms and legs and back and head started on 2 hours ago. The quality is sharp. The severity is 10/10. The duration is constant.” That sounds like the sentences our EHR used to produce — so stiff and inorganic! We would customize templates for clients but we could only do so much because we still had to work with that stiff sentence backbone that was native to the program we were using to create the templates. I definitely agree — in a world with Siri and virtual realities, there has got to be a way to create better health records.

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  13. Does the contract with the companies providing the software stipulate penalties if they fail to do what the contract says they should be doing? Often one finds that big companies do not get penalised when things don’t work as they should. Perhaps financial penalties would make suppliers sit up and take notice as no company (or individual for that matter) likes losing money.

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    • You know, I don’t think that is considered to be an industry standard. It ought to be. My salary is based on my performance so it would stand to reason theirs should, too. Technically we could sue for breach of contract but I am a little bitty fish in a big pond and without the support of other fed up physicians demanding change, nothing is likely to get any better.

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