More Problems With EHRs

My fourteen year old son had a sports physical yesterday.  At the end of the visit we were handed a sheaf of papers summarizing everything that had occurred.  We headed toward the lab for a blood draw, then drove home.  Finally, two hours after the appointment was over, I sat down to review the paperwork I’d received.  There it was:

EHR Problem

There are a few problems with this.  First, obviously, is that the information is wrong.  My son did not have his first menstrual period at age 13.

Second, poor programming permitted this error to occur.  When the patient is a male, it should not be possible to enter data in a “females only” section of the chart.  Either the entire section should be greyed-out, or selecting “male” in the gender field should generate an “N/A” entry in all female-only fields.  Worse, even for female patients, it should not be possible to enter any data in the second and third fields when the first question received a “no.”  This is incredibly sloppy programming.  If this is an example of the quality of work that’s gone into writing EHR software, it’s no wonder that it took an act of Congress to coerce physicians into purchasing this garbage.

After laughing at the typo, I checked the rest of the paperwork to make sure there weren’t any other surprises, then phoned our doctor’s office to request that they make the appropriate correction.  The receptionist was very nice, laughed with me, and promised to have the error fixed.

Problem:  at 5:30 our doctor phoned. The error can’t be fixed.  Once information is in an electronic chart, it can’t be changed.  What kind of numskull programmer doesn’t recognize the need for fallible humans to make corrections to typos?

Image getting a statement from your financial institution and finding that a decimal was in the wrong place –  that the check you wrote for $50 went through as $500.  Nobody would accept the bank saying, “Sorry, but once something is in the computer, it can’t be changed.”  Or what if your deposit was credited to another person’s account?  This happened to us once – fortunately my spouse keeps all deposit slips and checks them against the bank statement; it was relatively easy to resolve the problem because banks can make corrections to bad data.

It is possible to leave a trail showing that a correction was made: when, why, by whom, etc. The programming should then make it impossible for the old “bad” data to be copied and carried forward into future notes and communications.

In fact, the same programming would directly address misdiagnoses. Once a diagnosis is determined to be inaccurate and the true problem is discovered, it would not be difficult for a small addendum to appear throughout the chart whenever that misdiagnosis occurs, noting that on such-and-such a date, it was determined that the dx in question was more accurately replaced with a diagnosis of ___. The programming needs to ensure that the correct information, not the erroneous data, is what carries forward.

Electronic Health Records – a great idea in theory, but an abysmal failure in practice – have been inflicted on this country by the lawyers in DC who wrote the “Affordable” Care Act thinking that it’s appropriate for politicians to tell doctors how to do their jobs.  There are too many problems, from poor design, to bad programming, to the tendency to perpetuate inaccurate data.

All computer software need to be well-designed.  It needs to be tested and idiot-proofed.  Electronic health records are no different.  EHR software needs to acknowledge that fallible humans have a need to correct errors.  It’s true at the bank, and it’s even more true when people’s lives are at stake.

Online

Given a referral to a specialist, I wonder about seeing yet another physician.  My PCP is great; I trust that he’s sending me to a good doctor, but I’m still curious what to expect.  What does the person look like?  Which med school?  How old/experienced is the doctor?  Am I going to get lost trying to find the office?

Google can be great answering those questions.  It’s nice to type in the doctor’s name and find the practice’s website:  physician name, photo, CV, office hours, driving directions.  Everything I want to know is there.  I don’t have to interrupt the receptionist to get my answers.

When I was sent to an orthopedist, it was a bonus that the practice’s website was linked to their EMR.  Instead of phoning the office to set up an appointment and asking them to snail-mail me all the paperwork in advance, I was able to request an appointment online and fill-in-the-blanks electronically instead of filling out the paperwork longhand.  It was great!

At least it was great until I arrived for my appointment.  At check-in they confirmed everything I’d entered online, then handed me a ream of paperwork and explained that they were in the process of switching from paper charts to electronic, and needed everyone to fill in all the bubbles so that the information could be scanned into the computer.  When I pointed to her printouts and reminded her that my information was already in the new system, she took the Nazi defense (I’m just doing what I was told).

I spent 25 minutes filling out all the paperwork, repeating the information I’d entered online the week before and just confirmed at the check-in desk.

When I finally got to see the doctor, he had a paper chart in his hands, and I discovered that it was just the front office transitioning to EMR at that time.  Despite the doctor accusing me of being type-A, the visit went well.*  He did his exam, provided a treatment plan, and had me schedule a follow-up appointment.

When I returned eight weeks later, I was there the day the doctors went live with their new EMR.  Rather, they tried to go live.  Nobody was able to log in.  Lucky me.

My first appointment with him had gone well, but the second one was a disaster.  Even though I was the first appointment of the day, I sat in the waiting room an extra thirty minutes.  At 8:30 in the morning the doctor was already two patients behind, and finally decided to see patients whether the computer was working or not.  Unfortunately, the paper charts weren’t available.  The MA had jotted down some basic notes, but it was obvious that it didn’t give the doctor enough information to work with. With no paper chart and no EMR, the doctor walked into the room having only a vague idea who I was, why I was there, and what he was following up on.  He didn’t even know if the consultation note he’d been waiting for had arrived (it had, but I paid a whole lot of money to hear that he wouldn’t know what it said until they could get the computer working).

That’s a huge drawback to reliance on a computer.  When your system is down, does everything come to a grinding halt?

There needs to be a backup plan.  If the power is out, preventing computer access, it’s a problem.  If the software has a glitch, everyone’s stuck.  If patient records are half-way across the country and there’s a storm preventing internet access, patients might not get the treatment they need.  It doesn’t really matter what the excuse is.  If my doctor had stuck with paper charts, he would have had all the information he needed right at his fingertips.

The right software will make your job easier, not harder.   If it won’t easily give you the information you need when you need it, then it’s not the right software for you.  Computers are great tools, but they’re just tools.  Think of other tools.  I can grab a butter knife to tighten screws, but it’s easier (and more well done) to use a screwdriver.

Regardless of what business you’re in, smart shoppers don’t buy a database just so they can claim they’re computerized.  First figure out what information you need to keep track of and what you want to do with it, then find a program that meets the criteria.  That’s step one.

Step two is to invest in training.  You can figure out a $40 program from an instruction manual, but quality high-end programs should include training and transition assistance in the purchase contract.

Thorough training is essential.  So is a backup plan.  My orthopedist didn’t have either one.  I hate his EMR.

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*I’m not type-A; I’m just well organized.

First EMR

Saying “I hate EMRs” is like saying, “I hate seafood.”  There are just too many kinds to make sweeping generalizations.

I remember when I first heard the idea of using computers in a medical office.  Back in the late 70′s we had a VIC-20 at home*, and at school we had a TRS 80.  Personal computers were starting to be affordable by individuals (instead of those building-size contraptions only available to universities or large corporations).  The doctors for whom my mom worked were excited about the possibility of typing a patient’s symptoms into the computer and having a differential diagnosis print out.  Others scoffed at the notion, but nonetheless, people were starting to think that computers might be able to help in a medical setting.

Fast forward about twenty-five years.  The first time I saw a doctor using a computer for patient records was a good experience.  Instead of coming into the exam room with a paper chart, the Dr. Foote walked in with a laptop computer.  He loved his “new toy” as he called it.  The appointment went about the way a typical doctor’s appointment would go, but at the end, instead of writing notes in a paper chart, the doctor typed a few things into his computer.  On our way out, the receptionist handed us a typed prescription.  A fan of legibility, I thought that prescriptions printed from the computer were a fabulous idea.

Dr. Foote no longer carries a laptop into exam rooms.  He obviously reviews the patients’ charts before entering the exam rooms empty-handed.  He does whatever is needed, then returns to his desk to do his charting (computerized) before going on to the next patient.

From this patient’s perspective, it’s a process that works well.  It’s interesting that he does the same thing my family physicians does while using paper charts.

  • they review past history before coming into the room
  • they knows why I’m there
  • they focus on talking to me, not the chart (whether computer or paper)

I wish my other doctors who use EMRs did it as efficiently.

In the future, I’ll be writing about some of my other exposures to computerized medical records.
Have you had positive experiences with EMR?

 

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*upgraded to a Commodore 64 when I was in high school