EHR Bureaucrats Attempt to Remove the Human Side of Medicine
Unhappy Camper (Vol. 1, Issue 17)
I thought this week that I’d bring in some outside analysis of the whole EHR adoption thing from a non-medical source, Ziff-Davis that operates a multisite web presence for computer IT information and is the publisher of PC Magazine, among other popular journals.
To get started, see the post “Breaking doctor resistance to health IT” by Kavita Patel at: http://www.zdnet.com/blog/healthcare/breaking-doctor-resistance-to-healt... Note that I present this for review partly because Dr. Patel is a former Obama HHS official, and now a private think-tank analyst on the subject of EHR adoption.
Her first points are interesting and valid, in that doctors are being held responsible for mistakes inherent in their EHR systems, but have no or few legal remedies since we all must sign contracts that hold the EHR vendor harmless for such mistakes. Last week the American Medical Informatics Association released a position paper stating that "hold harmless" clauses in health IT contracts are unethical. Such clauses free health IT vendors from responsibility for errors or malfunctions of their technology. (http://www.ihealthbeat.org/articles/2010/11/11/amia-calls-for-accountabi... )
Certainly Ford and GM don’t require you to sign a contract that you hold their companies harmless if a product defect causes you to crash and burn. Informed surgical consent forms aside, our patients do not sign contracts promising not to sue us as their physicians. It seems to me that EHR vendors should be held to similar standards.
The second point Dr. Patel makes is that doctors are too resistant to using checklists to accomplish EHR documentation. What is particularly scary to me is that this former HHS official is proposing that this is how physicians now must think. Now, realize that I am in favor of EHR, and I do think that by rewarding quality care when proven, EHR may improve the quality of medical care overall. Doctors may need to accomplish certain tasks such as screening exams on their patients, perhaps with the assistance of checklists. But boiling down the practice of medicine to checklists is a very disturbing concept that removes any sense of the ‘art’ inherent in medicine. And unfortunately this seems to be the position held by many physician ‘champions’ who dedicate themselves to getting this task done—of forcing everyone to adopt EHR, no matter what.
The ‘art’ of medicine must be captured within the EHR for several good reasons. Foremost, it is the right thing to do if we’re to be the professionals we claim to be, and not robotic Cyborgs; for the practice of medicine is an encounter with a human being—not a data set.
I recall back this past August ( http://www.docehrtalk.org/messageboard/2010/08/07/unhappy-camper-vol-1-i... ) one vendor of a meaningful use organization was presenting all of the quality measures that his company would be seeking and presumably pay for. His company would be 'mining' for the data in EHR to show compliance with each quality measure. It was commented that, "So, you really don't care what else the physician is saying in his encounter note with the patient, you're just interested in mining that data." "Correct", he replied. As I had asked before, is this what the practice of medicine has come to?
At a recent medical-legal forum held in Warwick this past week, a panel of malpractice defense lawyers decried the lack of narrative notes in many EMR encounters. It is within such narratives that we show that we actually listened to a patient, or at least, know the patient well enough to have been caring and empathetic during the encounter. Automated checklists and templates that repeat the exact same information encounter to subsequent encounter do not capture these essential aspects. It is in a good narrative that might protect physicians in the event of an adverse event. Unfortunately, such narratives seem to be of little importance to the bureaucratic bean-counters that drive EHR down our throats, partly because the almighty ‘meaningful use’ criteria are not met while practicing the artful side of medicine.
We physicians need to push back against this pervasive new attitude. If we're to perform this money chase by submitting to meaningful use of our computerized medical records, we should at very least insist on respect for our role as physicians, and protect the human side of the doctor-patient relationship.
On a related note, last week, a New York Times blog entry titled "The Doctor vs. the Computer," at http://well.blogs.nytimes.com/2010/12/30/the-doctor-vs-the-computer/ generated much discussion. In the column, the author described how she could not document a complicated discussion with a patient because of a character limit for free text in her EHR (no mention of which product). The responses were interesting - many sympathized with her, but quite a few accepted this limitation and suggested workarounds, or even excused the software's "feature."
When we went through the EHR selection process five years ago, one important requirement was that users be able to enter information in the manner that was most comfortable for them, including typing free text or dictating. There are products that support narratives of any length, entered with a keyboard, voice recognition, or transcribed recording. Future users should avoid products that do not offer this feature.
The limitations of some EHR products add to the challenges raised in this thread. Careful selection of EHR's and advocating that the products that we use support the entry of free text in a meaningful way will help users avoid Dr. Ofri's dilemma. We need to remind all of the parties involved, including ourselves, to balance the need to capture information in ways that facilitate data exchange and reporting with the need to preserve, if not strengthen, the role of the medical record as documentation of "the patient's story."
Using an EHR? Yes - eClinicalWorks
Disclosure: Shareholder of Coastal Medical, Inc.
Thank you for posting this reply Yul. I have to admit that getting through editorials is lower on my priority list as I try to keep up with everything going on around me. Based upon Dr. Barr's excellent editorial I guess I will need to re-prioritize and take note of them more often, particularly in the Annals.
I submitted a request to post the full editorial on www.ecwusers.com as I think it is great reading, can stimulate discussion and possibly refinements of the EMR that I use for the better. I do our in-house training and lead my group's peer review activities. We are always stressing that yes, we need to see the details, but we just as importantly need to see the thought process behind the care provided. Document what the patient is thinking, document what the physician is thinking, make it a useful encounter rather than a smoke cloud filled with minutia that bean counters want to see. Make the clinical record useful for the providers and readers to understand what is going on with the patient and the patient's care. We are definitely moving in the right direction, we have to continue to adjust along the way to make sure things are relevant and sensible.
Using an EHR? Yes - eClinicalWorks
Disclosure: Owner/practicing partner of Aquidneck Medical Associates, Inc. Contracted as the Case Management Physician Advisor at Newport Hospital (a Lifespan affiliate) and as an advisor for BCBS of RI to help facilitate HIT integration in community practices
My friend and colleague at ACP Dr. Michael Barr, who is Senior Vice President of the newly-established Division of Medical Practice, Professionalism & Quality, wrote an editorial in the November 15 Annals of Internal Medicine that commented on two articles in that issue. One article was a description of the "Feds'" efforts to support meaningful use, and the other was a historical perspective on the medical record. The editorials can be found at http://www.annals.org/content/153/10/682.full, but for those without full access, I excerpted the last few paragraphs of the editorial, where Michael makes the point that it need not be "either/or" when it comes to preserving the richness of the record that Dr. Concannon fears losing while we use our EHRs in ways not possible with the paper record:
Perhaps we now have the opportunity to deliver on Reiser's vision. Electronic health records with well-designed, structured data sets balanced with clinical narrative could help accelerate research and facilitate better care through such functions as real-time quality dashboards and timely clinical decision support. Schiff and Bates (9) call on system developers to “reconceptualize documentation workflow” and create a place where “clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions.” They describe several ways that EHRs could help prevent diagnostic errors and create safer care. Clinical decision support at the point of care is one promising function of EHRs, but it depends on accurate and complete clinical documentation that is collected and entered in ways that permit the decision-support systems to provide the best information available (10). It will be important for clinical decision support to somehow incorporate narrative impressions with structured data to generate the most meaningful recommendations.
Electronic health records should be used as a tool to support clinical curiosity and critical thinking rather than simply to expedite clinically meaningless documentation in order to bill higher codes. We are in danger of repeating history by once again overstructuring the clinical record and overloading it with extraneous data. Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach—to the detriment of patient care.
Do we want medical historians of the 23rd century to look back at our time and question why physicians clouded clinical records with extraneous, irrelevant, and repetitive documentation? Or do we want future generations to regard our time as a period during which applied informatics enabled rapid evolution of the clinical record and associated advances in clinical knowledge, educational models, and better health for the people we served? We must face 21st-century challenges with the experience gained over 200 years and carry forward the rich history of the clinical record.
Using an EHR? Yes - eClinicalWorks
Disclosure: Shareholder of Coastal Medical, Inc.