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  • A Critique of Electronic Health Records Systems

    Posted by David Foster on November 22nd, 2018 (All posts by )

    …with extension to other kinds of application software.

    At the New Yorker, of all place:  Why Doctors Hate Their Computers.

    See also this 2012 article in the Atlantic.

    [Jonathan adds: See also this 2009 Chicago Boyz post and discussion.]


    8 Responses to “A Critique of Electronic Health Records Systems”

    1. Mike K Says:

      the design choices were more political than technical: administrative staff and doctors had different views about what should be included.

      That is a key observation in a very good article. Late in the article, it starts to talk about advantages of the system but look at what is said. It puts the Medical Director, and that means administrators, in control of doctors. I think that is a lot of the burnout.

      I quit teaching because of the EHR. I wrote a letter to the Dean of the medical school complaining that instructors did not have passwords into the system and that the system did not allow us to see the patents histories, which I had always reviewed while my students were interviewing and examining them. That way, I could see if they missed things.

      The Dean called me and told me that what I had written could not possibly be true. I asked him when he had last used the system.

      Not too long after this he was fired and was found to have been using cocaine and spending his time partying.

      No wonder he didn’t;t know what I was complaining about.

      I was once an enthusiast for electronic records, which I thought could relieve a lot of the work of doctors. But the system as designed did the opposite. We had a meeting of the faculty about the new EHR and I learned that almost all said it reduced their efficiency by at least 25%.

    2. Mike K Says:

      Since medical care as a whole is consolidating, the basic question is whether emerging EMR vendors will gain enough traction and offer enough capability to enable stand-alone practices to remain independent. Or will platform fragmentation put unaffiliated practices at such a competitive disadvantage that they’ll be even more motivated to join up with larger hospital systems (the most important of which will rely upon Epic)?

      Another key observation in the other article. We are heading into an era of industrial medical care. Obamacare was popular with administrators as it would help them win their war on doctors. Medicine is now the most regulated profession there is.

      Epic’s success suggests that it has locked onto something that its key clients – academic medical centers and large health systems — need most right now. This burning need, it turns out, isn’t the capacity for bubbled-up innovation. What they need is the quick and flawless imposition of structure – pushed down from above, and proprietary if necessary.

      The tertiary hospital is a vast enterprise with incredibly complex array of care delivery, with a wide web of participating – and very vocal, idiosyncratic – stakeholders involved. It faces long-term pressures – e.g. care shifting from the hospital to ambulatory settings – and shorter-term pressures with more uncertain endpoints – e.g. reimbursement changes, regulatory requirements. They need someone to step in and define the information sharing processes for the system,

      Obamacare destroyed the system we had, which 80% of the population was content with. It was too expensive but there was a lot of cost shifting. The insured were paying for the indigent. Administrative costs went way up as people pushed insurance to pay for routine care. The cost of processing claims became a huge part of it,

    3. Gavin Longmuir Says:

      Fortunately, I am healthy — partly due to genetics, and partly to a judicious regime of regularly flushing the system with alcohol. But I have had to see doctors a few times over the last several years, mainly for administrative reasons. In every case, the doctors (all fine knowledgeable practitioners, as far as I could tell) sat at 90 degrees to the patient, staring at their computer screens. The former practice of the doctor closely observing the patient and carefully noting eyes, ears, fingernails, skin tone, movements seems to have gone — with a probable reduction in the quality of diagnosis.

      The strange thing is that we know how to provide high quality modern medicine effectively, efficiently, safely, and at reasonable cost — and we do it every day. Just visit your local veterinarian, where regulation is still at a sensible level.

      Oh well! Let’s be grateful for whatever crumbs the bureaucrats allow us to keep. Happy Thanksgiving, everyone!

    4. David Foster Says:

      “What they (tertiary hospitals) need is the quick and flawless imposition of structure – pushed down from above, and proprietary if necessary.”

      I know of a hospital which implemented a common system to replace multiple departmental systems. The new system had interesting features like requiring an obstetrician to respond to a question about the health of a patient’s prostate. In this case, there was a successful rebellion of the medical personnel.

    5. Mike K Says:

      The hospital where I practiced for 25 years, was sold to an order of nuns after I retired. They have changed it so much that I would not allow myself to be hospitalized there now.

      They chose a CEO who had been an executive with Pepsico but had no healthcare experience. He appointed his brother-in-law, a chiropractor, as chief of the Surgery Services department. My wife had been having serious health problems with emphysema and was hospitalized twice there. In both cases, she was retired to “donate” $500 to be admitted. She was a Medicare beneficiary at the time. Fortunately, her health has improved with a new biological drug that has corrected some immune system problems.

      A friend, a gastroenterologist I know well, has a very well equipped endoscopy suite and office adjacent to the hospital. He has had it for 30 years. The hospital recently contacted him and “suggested” that he do some of his endoscopies in the hospital suite. Since the hospital, bought all the medical practices in the building, his sources of referrals, he decided he would do some there. He asked to review some records to see what they were doing. He told a friend that all the records he saw showed evidence of fraud, mostly excessive lab work.

      The “Industrial Model” of healthcare is not something I want to deal with. In Tucson, there is a hospital not far but we have not needed care. I did have an outpatient surgery on my elbow a year ago and that was done well.

    6. Bruce Says:

      “Another key observation in the other article. We are heading into an era of industrial medical care. Obamacare was popular with administrators as it would help them win their war on doctors. Medicine is now the most regulated profession there is.”

      One of the things that I hate, hate, hate, is that so much of the practice has gone corporate. You can no longer get ahold of your primary care provider directly nor their assistant. You end up calling up their receptionist service invariably not located anywhere near them, and the receptionist sends the assistant an email, which they eventually may see. Then the assistant asks their provider the question, and puts the response in your records, which the receptionist can read off to you the next time you call back, after pressing this key and that key, then, with my wife’s provider, having to press some random specified key every five minutes or so while you are on hold, otherwise going to voice mail. Sure, you can ask them to call you back, which they sometimes do. But sometimes you just have to spend another half hour calling them back. (I should add that this problem doesn’t seem to have affected our specialists yet). Hope Obama and the Democrats are happy at what they wrought.

    7. Mike K Says:

      Hope Obama and the Democrats are happy at what they wrought.

      What is happening in Canada and in Britain is that those who can afford private care are getting it. A few years ago, the population of southeast England, which is the only part with a positive GDP, 25% had private health insurance.

      Canada is getting private clinics, which our resident troll from Vancouver denies, but it is happening.

      WE have some cash practices here. I was interested to see all the “Urgent Care” clinics in Tucson. I wonder how many are cash providers?

      To do so, you have to drop Medicare and most insurance.

    8. Jonathan Says:

      Just visit your local veterinarian, where regulation is still at a sensible level.

      Imagine, at every step of treatment, having the doctor’s assistant tell you up-front what your options are and how much they cost. Crazy talk, I know.

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